ACORD 71 (2012/03)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 71 (2012/03)
Personal Auto Policy Change
Request
ACORD 71, Personal Auto Policy Change Request, is used to
request mid-term changes to any personal auto policy. The form should be used instead
of individual turnaround endorsement requests. A copy of the request may be sent to the
insured to confirm that the change is submitted to the company.
IDENTIFICATION SECTION Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone No.
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No.
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
ACORD 71 (2012/03) rev. 03-30-2012
1 of 49
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Insured Name and Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page. As
used here, the Insured Name and Mailing Address should only be used if a portion of it
has changed.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION Garaging Address (checkbox)
Indicate if Mailing Address is
Check the box (if applicable): Indicates the mailing address is the primary garaging
address.
IDENTIFICATION SECTION Tax Code
Enter code: The city, county or state tax code. As used here, enter the tax code only if it
has changed.
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.
IDENTIFICATION SECTION Attention
Enter text: The name of the individual at the insurance company that is the primary
contact.
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 Account Number
Enter identifier: The account number to be used for billing purposes. This is the billing
number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the
insurer assigns. If the account already exists, the agent should provide the previously
assigned number.
IDENTIFICATION SECTION Effective Date of Change
Enter date: The date on which the change should take effect.
IDENTIFICATION SECTION Effective Date of Policy
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
ACORD 71 (2012/03) rev. 03-30-2012
2 of 49
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Change Billing Plan to Direct
Check the box (if applicable): Indicates if the policy is to be direct billed. As used here,
only check if the billing plan is changing.
IDENTIFICATION SECTION Agency
Change Billing Plan to Direct
Check the box (if applicable): Indicates if the policy is to be producer/agency billed. As
used here, only check if the billing plan is changing.
GARAGING ADDRESS(ES)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
GARAGING ADDRESS
Loc
Enter number: The producer assigned number of the location.
GARAGING ADDRESS
Street
Enter text: The vehicle's physical address line one.
GARAGING ADDRESS
City
Enter text: The vehicle's physical address city name.
GARAGING ADDRESS
County
Enter text: The vehicle's physical address county name.
GARAGING ADDRESS
State
Enter code: The vehicle's physical address state or province code.
GARAGING ADDRESS
Zip
Enter code: The vehicle's physical address postal code.
GARAGING ADDRESS
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
GARAGING ADDRESS
Loc
Enter number: The producer assigned number of the location.
GARAGING ADDRESS
Street
Enter text: The vehicle's physical address line one.
GARAGING ADDRESS
City
Enter text: The vehicle's physical address city name.
GARAGING ADDRESS
County
Enter text: The vehicle's physical address county name.
ACORD 71 (2012/03) rev. 03-30-2012
3 of 49
Section Name
Field Name
Field and/or Section Description
GARAGING ADDRESS
State
Enter code: The vehicle's physical address state or province code.
GARAGING ADDRESS
Zip
Enter code: The vehicle's physical address postal code.
VEHICLE DESCRIPTION /
USE
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE DESCRIPTION /
USE
Veh
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
Loc
Enter number: The producer assigned number of the location.
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
Reg St
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Reg to Drv #
Enter number: The producer assigned driver number for whom 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 text: The month and year the applicant leased the vehicle (MM/YYYY).
VEHICLE DESCRIPTION /
USE
Date Purch
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
ACORD 71 (2012/03) rev. 03-30-2012
4 of 49
Section Name
Field Name
Field and/or Section Description
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
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION /
USE
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION /
USE
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION /
USE
Mile 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
Car Pool
Enter Y for a Yes response. Input N for No response. Indicates if a carpool discount
applies.
ACORD 71 (2012/03) rev. 03-30-2012
5 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE DESCRIPTION /
USE
Gar Code
Enter code: The garaging code of the vehicle (where the vehicle is parked at night).
Select from the following options:
A - Garaged at School
B - Off street at school
C - On street at school
D - Driveway
G - Garaged
N - Not garaged (if other options do not apply)
O - Off street
P - Parking Lot
R - Carport
S - Street
VEHICLE DESCRIPTION /
USE
Odometer Reading
Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION /
USE
Annual Mileage
Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION /
USE
Govern Driver
Enter number: The producer assigned driver number of the driver assigned to the vehicle
for rating purposes.
VEHICLE DESCRIPTION /
USE
Driver # 1
Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver # 2
Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver # 3
Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver # 4
Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver # 5
Enter number: The producer assigned driver number of the driver using the vehicle.
ACORD 71 (2012/03) rev. 03-30-2012
6 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver # 6
Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Veh
Enter number: The producer assigned vehicle number.
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
Passive Seat Belt
Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION /
USE
Air Bag
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
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE DESCRIPTION /
USE
Veh
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
Loc
Enter number: The producer assigned number of the location.
ACORD 71 (2012/03) rev. 03-30-2012
7 of 49
Section Name
Field Name
Field and/or Section Description
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
Reg St
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Reg to Drv #
Enter number: The producer assigned driver number for whom 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 text: The month and year the applicant leased the vehicle (MM/YYYY).
VEHICLE DESCRIPTION /
USE
Date Purch
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
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
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION /
USE
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION /
USE
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION /
USE
Mile 1 Way Wk/Schl
Enter number: The number of miles from the garage location to school or work.
ACORD 71 (2012/03) rev. 03-30-2012
8 of 49
Section Name
Field Name
Field and/or Section Description
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
Car Pool
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.
ACORD 71 (2012/03) rev. 03-30-2012
9 of 49
Section Name
Field Name
Field and/or Section Description
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
Veh
Enter number: The producer assigned vehicle number.
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
Passive Seat Belt
Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION /
USE
Air Bag
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 COVERAGES
(excluding NO FAULT)
Vehicle #
Enter number: The producer assigned vehicle number.
VEHICLE COVERAGES
(excluding NO FAULT)
Single Limit Liability (CSL) Type
Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ACORD 71 (2012/03) rev. 03-30-2012
10 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Single Limit Liability (CSL) Ea
Accident
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Ea Person
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Ea Accident
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability Ea
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).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability
Deductible
Enter deductible: The property damage deductible amount.
ACORD 71 (2012/03) rev. 03-30-2012
11 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Medical Payments Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Medical Payments Ea Person
Enter limit: The medical payments per person limit.
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Type
Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Ea
Person
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Ea
Accident
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL / BI
Option
Enter text: The description of the options applicable to uninsured motorists coverage.
ACORD 71 (2012/03) rev. 03-30-2012
12 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist PD Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist PD Ea
Accident
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI Ea
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
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI Ea
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.
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL / BI
Option
Enter text: The description of the options applicable to underinsured motorists coverage.
ACORD 71 (2012/03) rev. 03-30-2012
13 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist PD Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist PD Ea
Accident
Enter limit: The underinsured motorists property damage per accident amount. The use
of this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive/ OTC Deductible
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive/ OTC Deductible
Amount
Enter deductible: The comprehensive or other than collision deductible amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive / OTC Option
Enter text: The description of the options applicable to comprehensive / other than
collision coverage.
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Deductible Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ACORD 71 (2012/03) rev. 03-30-2012
14 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Deductible Amount
Enter deductible: The collision deductible amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Option
Enter text: The description of the options applicable to collision coverage.
VEHICLE COVERAGES
(excluding NO FAULT)
ACV Unless Amt Stated Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
ACV Unless Amt Stated Limit
Enter limit: The limit associated with comprehensive and collision coverage is the actual
cash value of the vehicle, unless an amount is stated here.
VEHICLE COVERAGES
(excluding NO FAULT)
Towing & Labor Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Towing & Labor Limit
Enter limit: The towing and labor limit amount.
ACORD 71 (2012/03) rev. 03-30-2012
15 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense / Rental
Reimbursement Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense Ea Day
Enter limit: The transportation expense or rental reimbursement per day limit amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense Maximum
Limit
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Vehicle #
Enter number: The producer assigned vehicle number.
VEHICLE COVERAGES
(excluding NO FAULT)
Single Limit Liability (CSL) Type
Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Single Limit Liability (CSL) Ea
Accident
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
ACORD 71 (2012/03) rev. 03-30-2012
16 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Ea Person
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
VEHICLE COVERAGES
(excluding NO FAULT)
Bodily Injury Liability Ea Accident
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability Ea
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).
VEHICLE COVERAGES
(excluding NO FAULT)
Property Damage Liability
Deductible
Enter deductible: The property damage deductible amount.
ACORD 71 (2012/03) rev. 03-30-2012
17 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Medical Payments Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Medical Payments Ea Person
Enter limit: The medical payments per person limit.
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Type
Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Ea
Person
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL/BI Ea
Accident
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist CSL / BI
Option
Enter text: The description of the options applicable to uninsured motorists coverage.
ACORD 71 (2012/03) rev. 03-30-2012
18 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist PD Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Uninsured Motorist PD Ea
Accident
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI Ea
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
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL/BI Ea
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.
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist CSL / BI
Option
Enter text: The description of the options applicable to underinsured motorists coverage.
ACORD 71 (2012/03) rev. 03-30-2012
19 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist PD Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Underinsured Motorist PD Ea
Accident
Enter limit: The underinsured motorists property damage per accident amount. The use
of this limit varies by state.
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive / OTC Deductible
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive/ OTC Deductible
Amount
Enter deductible: The comprehensive or other than collision deductible amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Comprehensive / OTC Option
Enter text: The description of the options applicable to comprehensive / other than
collision coverage.
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Deductible Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ACORD 71 (2012/03) rev. 03-30-2012
20 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Deductible Amount
Enter deductible: The collision deductible amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Collision Option
Enter text: The description of the options applicable to collision coverage.
VEHICLE COVERAGES
(excluding NO FAULT)
ACV Unless Amt Stated Type Of
Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
ACV Unless Amt Stated Limit
Enter limit: The limit associated with comprehensive and collision coverage is the actual
cash value of the vehicle, unless an amount is stated here.
VEHICLE COVERAGES
(excluding NO FAULT)
Towing & Labor Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Towing & Labor Limit
Enter limit: The towing and labor limit amount.
ACORD 71 (2012/03) rev. 03-30-2012
21 of 49
Section Name
Field Name
Field and/or Section Description
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense/Rental
Reimbursement Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense Ea Day
Enter limit: The transportation expense or rental reimbursement per day limit amount.
VEHICLE COVERAGES
(excluding NO FAULT)
Transportation Expense Maximum
Limit
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
REMARKS
Remarks
Enter text: The remarks associated with a policy change. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required.
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ACORD 71 (2012/03) rev. 03-30-2012
22 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
23 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
24 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
25 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
26 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
27 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
28 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
29 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
30 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
31 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
32 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
33 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
34 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
35 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
36 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
37 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ACORD 71 (2012/03) rev. 03-30-2012
38 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Type of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Veh
Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Code
Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Description
Enter text: The description of the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit
Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Limit Applies to
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Amount
Enter deductible: The deductible amount of the coverage.
ACORD 71 (2012/03) rev. 03-30-2012
39 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Deductible Percentage
Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE
COVERAGES (including NO
FAULT)
Option
Enter code: The option applicable to this coverage.
DRIVER INFORMATION
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
First Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Last Name
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
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/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I -
Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
ACORD 71 (2012/03) rev. 03-30-2012
40 of 49
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
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.
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.
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.
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.
DRIVER INFORMATION
Drivers License #
Enter identifier: The driver's license number.
DRIVER INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
First Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Last Name
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
ACORD 71 (2012/03) rev. 03-30-2012
41 of 49
Section Name
Field Name
Field and/or Section Description
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/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
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.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
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.
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.
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.
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.
DRIVER INFORMATION
Drivers License #
Enter identifier: The driver's license number.
DRIVER INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
ACORD 71 (2012/03) rev. 03-30-2012
42 of 49
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Type Of Change
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
First Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Last Name
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
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/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
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.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver #
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
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.
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.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
ACORD 71 (2012/03) rev. 03-30-2012
43 of 49
Section Name
Field Name
Field and/or Section Description
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.
DRIVER INFORMATION
Drivers License #
Enter identifier: The driver's license number.
DRIVER INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
ACCIDENTS /
CONVICTIONS
Has Any Driver Shown Above Had
An Accident, Regardless Of Fault,
Or Been Convicted Of A Moving
Violation Within The Last _____
Years?
Enter number: The number of years associated with an accident... or convicted of a
moving violation question.
ACCIDENTS /
CONVICTIONS
Accident 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.
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. ACORD 101, Additional
Remarks Schedule, should be attached if more space is needed.
ACCIDENTS /
CONVICTIONS
Place of Accident / Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS /
CONVICTIONS
Bodily Injury Or Death Y / N
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.
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. ACORD 101, Additional
Remarks Schedule, should be attached if more space is needed.
ACCIDENTS /
CONVICTIONS
Place of Accident / Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS /
CONVICTIONS
Bodily Injury Or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or
conviction resulted in bodily injury or death.
ACORD 71 (2012/03) rev. 03-30-2012
44 of 49
Section Name
Field Name
Field and/or Section Description
ACCIDENTS /
CONVICTIONS
Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
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. ACORD 101, Additional
Remarks Schedule, should be attached if more space is needed.
ACCIDENTS /
CONVICTIONS
Place of Accident / Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS /
CONVICTIONS
Bodily Injury Or Death Y / N
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.
GENERAL INFORMATION
1. With the exception of any
encumbrances, are any vehicles
not solely owned by and
registered to the applicant?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question With the exception of any encumbrances, are any vehicles, for which insurance
is requested not solely owned by and registered to the applicant?.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Name of Other Owner
Enter text: The additional interest's full name.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Name of Other Owner
Enter text: The additional interest's full name.
GENERAL INFORMATION
2. Any car modified / special
equipment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question Any vehicles customized, altered or with special equipment?.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Description
Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION
Cost
Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Description
Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION
Cost
Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION
3. Any existing damage to vehicle?
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.
ACORD 71 (2012/03) rev. 03-30-2012
45 of 49
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
4. Any household member in
military service?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question Any household member in military service?.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Branch
Enter text: The branch of military service.
GENERAL INFORMATION
Rank
Enter text: The driver's rank in the military.
GENERAL INFORMATION
Base Location - Street
Enter text: The military base's first address line.
GENERAL INFORMATION
Base Location - City
Enter text: The city of the military base.
GENERAL INFORMATION
Base Location - State
Enter code: The state or province code of the military base.
GENERAL INFORMATION
Base Location - Zip
Enter code: The postal code of the military base.
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
5. Any drivers license been
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.
IDENTIFICATION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
GENERAL INFORMATION
6. Any driver have a physical
impairment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question Any driver have physical impairment?. As used here, not applicable in MT and
WI.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Description of Special Equipment
in Vehicle
Enter text: The description of any special equipment.
GENERAL INFORMATION
7. Any driver undergoing a course
of medical treatment for a physical
/ mental impairment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Any driver undergoing a course of medical treatment for a physical or mental
impairment?. As used here, not applicable in MT, OR and WI.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Explanation
Enter text: The description of any medication or treatments for a driver with physical or
mental impairments.
GENERAL INFORMATION
(Continued)
8. 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?.
ACORD 71 (2012/03) rev. 03-30-2012
46 of 49
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(Continued)
Reason for Filing
Enter text: The description of why a financial responsibility filing is required.
GENERAL INFORMATION
(Continued)
Filing Date
Enter date: The date on which the financial responsibility filing was originally required.
GENERAL INFORMATION
(Continued)
8. 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
(Continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(Continued)
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.
ADDITIONAL INTEREST
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
ADDITIONAL INTEREST
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
ADDITIONAL INTEREST
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST
Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Owner
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST
Registrant
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests
are associated with the same item.
ADDITIONAL INTEREST
Name and Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Enter code: The additional interest's country code.
ACORD 71 (2012/03) rev. 03-30-2012
47 of 49
Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional
interest.
ADDITIONAL INTEREST
Location
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
ADDITIONAL INTEREST
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
ADDITIONAL INTEREST
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST
Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Owner
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST
Registrant
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests
are associated with the same item.
ADDITIONAL INTEREST
Name And Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Enter code: The additional interest's country code.
ADDITIONAL INTEREST
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional
interest.
ADDITIONAL INTEREST
Location
Enter number: The producer assigned number of the location which has an additional
interest.
ACORD 71 (2012/03) rev. 03-30-2012
48 of 49
Section Name
Field Name
Field and/or Section Description
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
Producer's Name (Please Print)
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer.
SIGNATURE
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
National Producer Number
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
state license number.
EDITION
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 71 (2012/03) rev. 03-30-2012
49 of 49