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ACORD Form 99 Accidents /
Convictions Section Instructions
 

 
ACORD 99 (2009/02) rev. 02-27-2009 1 of 14
Section Name Field Name Field and/or Section Description
TITLE ACORD 99 (2009/02) Accidents / Convictions Schedule The title of the form. ACORD 99, Accidents / Convictions Schedule, is used as an attachment to the ACORD Personal Auto Application (90s) or other forms, when more space is required for accidents and convictions.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Page _ Enter number: The page number applicable to this page.
IDENTIFICATION SECTION Of _ Enter number: The total number of pages applicable to this form (e.g., Page 1 of 4). If only one page, indicate Page 1 of 1.
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
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.
IDENTIFICATION SECTION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).
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.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACORD 99 (2009/02) rev. 02-27-2009 2 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 3 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 4 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 5 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 6 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 7 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 8 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 9 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 10 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 11 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 12 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
ACORD 99 (2009/02) rev. 02-27-2009 13 of 14
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
Remarks Schedule, if more space is needed. As used here, include the number of
ACCIDENTS / Description of Accident or vehicles involved and the type of vehicles (private passenger or commercial). Convictions
CONVICTIONS Conviction constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
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.
Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attached ACORD 101, Additional Remarks Schedule, if more space is needed. As used here, include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail.
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 conviction resulted in bodily injury or death.
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / As used here, includes both the applicant's and all claimant's combined damages. Refer
CONVICTIONS Amount of Property Damage to company manual.
IDENTIFICATION SECTION Initials Initial here: The named insured's initials.
The edition identifier of the form including the form number and edition (the date is
Edition Date typically formatted YYYY/MM).

ACORD 99 (2009/02) rev. 02-27-2009 14 of 14