ACORD 99 (2009/02)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 99 (2009/02)
Accidents / Convictions Schedule
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
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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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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.
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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
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
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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 /
CONVICTIONS
BI or Death
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
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.
As used here, includes both the applicant's and all claimant's combined damages. Refer
to company manual.
IDENTIFICATION SECTION Initials
Initial here: The named insured's initials.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 99 (2009/02) rev. 02-27-2009
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