Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 90 MA (2012/08)
Application For Massachusetts
Motor Vehicle Insurance
ACORD 90 MA, Application for Massachusetts Motor Vehicle
Insurance, is used when insurance is desired for personal vehicles. ACORD 90 MA is
entirely different than applications in other states.
The state of Massachusetts requires personal automobile, new business and renewals, to
be submitted on forms that are prescribed by the Massachusetts Commissioner of
Insurance. ACORD 90 MA, Application for Massachusetts Motor Vehicle Insurance,
meets the prescribed requirements. Questions or comments regarding this form should be
directed to the Massachusetts Automobile Insurers Bureau (www.aib.org).
This application is designed for up to two vehicles and four operators. If these limits are
insufficient, attach an additional ACORD 90 MA.
IDENTIFICATION SECTION
Producer
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION
POL#
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION
Company Use
Enter text: This area is to be completed by the insurer.
IDENTIFICATION SECTION
Applicant's Name and Mailing
Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's physical address line one.
IDENTIFICATION SECTION
Enter text: The named insured's physical address line two.
IDENTIFICATION SECTION
Enter text: The named insured's physical address city name.
IDENTIFICATION SECTION
Enter text: The applicant's physical address county name.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Enter code: The named insured's physical address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's physical address postal code.
IDENTIFICATION SECTION
Telephone Number
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION
Mailing Address
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
Direct Bill
Check the box (if applicable): Indicates if the policy is to be direct billed.
IDENTIFICATION SECTION
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
IDENTIFICATION SECTION
Payment Plan
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -
Quarterly, etc.).
RESIDENCE
Deposit Premium
Enter amount: The amount of the premium received as a deposit.
COVERAGES PART 1-12
Auto 1 Bodily Injury to others
$20,000 per person/$40,000 per
accident premium amount
Enter amount: The vehicle policy, bodily injury per accident premium amount.
COVERAGES PART 1-12
Auto 1 Personal Injury Protection
Deductible Amount
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES PART 1-12
Auto 1 Personal Injury Protection
Yourself
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
COVERAGES PART 1-12
Auto 1 Personal Injury Protection
Yourself & Household Members
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
COVERAGES PART 1-12
Auto 1 Personal Injury Protection
Premium Amount
Enter amount: The premium associated with personal injury protection (PIP) coverage.
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Section Name
Field Name
Field and/or Section Description
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
uninsured auto (compulsory limits
$20,000/$40,000) per 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.)
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
uninsured auto (compulsory limits
$20,000/$40,000) per 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.
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
uninsured auto Premium Amount
Auto 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
COVERAGES PART 1-12
Auto 1 Damage to someone else's
property (compulsory limit $5,000)
per accident
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES PART 1-12
Auto 1 Damage to someone else's
property premium amount
Enter amount: The property damage premium amount.
COVERAGES PART 1-12
Auto 1 Optional Bodily Injury To
Others Per Person
Enter limit: The optional bodily injury to others per person limit amount.
COVERAGES PART 1-12
Auto 1 Optional Bodily Injury To
Others Per Accident
Enter limit: The optional bodily injury to others per accident limit amount.
COVERAGES PART 1-12
Auto 1 Optional Bodily Injury To
Others Per Premium Amount
Enter amount: The optional bodily injury to other premium amount.
COVERAGES PART 1-12
Auto 1 Medical Payments Per
Person
Enter limit: The medical payments per person limit.
COVERAGES PART 1-12
Auto 1 Medical Payments Per
Person Premium Amount
Enter amount: The medical payments premium amount.
COVERAGES PART 1-12
Auto 1 Collision Waiver of
Deductible
Check the box (if applicable): Indicates the insured has selected the waiver of collision
deductible option.
COVERAGES PART 1-12
Auto 1 Collision Deductible
Enter deductible: The collision deductible amount.
COVERAGES PART 1-12
Auto 1 Collision Premium Amount
Enter amount: The collision premium amount.
COVERAGES PART 1-12
Auto 1 Limited Collision
Deductible
Enter deductible: The collision deductible amount.
COVERAGES PART 1-12
Auto 1 Limited Collision Premium
Amount
Enter amount: The collision premium amount.
ACORD 90 MA (2012/08) rev. 07-31-2012
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Section Name
Field Name
Field and/or Section Description
COVERAGES PART 1-12
Auto 1 Comprehensive $100 Glass
Deductible
Check the box (if applicable): Indicates a $100 glass deductible applies to the
comprehensive coverage.
COVERAGES PART 1-12
Auto 1 Comprehensive Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES PART 1-12
Auto 1 Comprehensive Premium
Amount
Enter amount: The comprehensive or other than collision premium amount. In Texas this
is the comprehensive premium amount only.
COVERAGES PART 1-12
Auto 1 Substitute Transportation
Up To $ A Day
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES PART 1-12
Auto 1 Substitute Transportation $
Max
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES PART 1-12
Auto 1 Substitute Transportation
Premium Amount
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES PART 1-12
Auto 1 Towing and Labor Up to $
for each disablement
Enter limit: The towing and labor limit amount.
COVERAGES PART 1-12
Auto 1 Towing and Labor Premium
Amount
Enter amount: The towing and labor premium amount.
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
underinsured auto per person
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
underinsured auto per accident
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
COVERAGES PART 1-12
Auto 1 Bodily Injury caused by an
underinsured auto premium
amount
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount.
COVERAGES PART 1-12
Auto 1 Safe Driver Insurance Plan
(SDIP) Premium Adjustment
Enter amount: The premium adjustment amount for the merit rating plan.
COVERAGES PART 1-12
Auto 1 Guest Occupant Exclusion
for Motorcycle
Check the box (if applicable): Indicates guest occupant exclusion applies for motorcycles.
COVERAGES PART 1-12
Auto 1 Guest Occupant Exclusion
for Motorcycle Premium Amount
Enter amount: The guest occupant exclusion for motorcycles premium amount.
COVERAGES PART 1-12
Auto 2 Bodily Injury to others
$20,000 per person/$40,000 per
accident premium amount
Enter amount: The vehicle policy, bodily injury per accident premium amount.
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Section Name
Field Name
Field and/or Section Description
COVERAGES PART 1-12
Auto 2 Personal Injury Protection
Deductible Amount
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES PART 1-12
Auto 2 Personal Injury Protection
Yourself
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
COVERAGES PART 1-12
Auto 2 Personal Injury Protection
Yourself & Household Members
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
COVERAGES PART 1-12
Auto 2 Personal Injury Protection
Premium Amount
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
uninsured auto (compulsory limits
$20,000/$40,000) per 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.)
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
uninsured auto (compulsory limits
$20,000/$40,000) per 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.
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
uninsured auto Premium Amount
Auto 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
COVERAGES PART 1-12
Auto 2 Damage to someone else's
property (compulsory limit $5,000)
per accident
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES PART 1-12
Auto 2 Damage to someone else's
property premium amount
Enter amount: The property damage premium amount.
COVERAGES PART 1-12
Auto 2 Optional Bodily Injury To
Others Per Person
Enter limit: The optional bodily injury to others per person limit amount.
COVERAGES PART 1-12
Auto 2 Optional Bodily Injury To
Others Per Accident
Enter limit: The optional bodily injury to others per accident limit amount.
COVERAGES PART 1-12
Auto 2 Optional Bodily Injury To
Others Per Premium Amount
Enter amount: The optional bodily injury to other premium amount.
COVERAGES PART 1-12
Auto 2 Medical Payments Per
Person
Enter limit: The medical payments per person limit.
COVERAGES PART 1-12
Auto 2 Medical Payments Per
Person Premium Amount
Enter amount: The medical payments premium amount.
ACORD 90 MA (2012/08) rev. 07-31-2012
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Section Name
Field Name
Field and/or Section Description
COVERAGES PART 1-12
Auto 2 Collision Waiver of
Deductible
Check the box (if applicable): Indicates the insured has selected the waiver of collision
deductible option.
COVERAGES PART 1-12
Auto 2 Collision Deductible
Enter deductible: The collision deductible amount.
COVERAGES PART 1-12
Auto 2 Collision Premium Amount
Enter amount: The collision premium amount.
COVERAGES PART 1-12
Auto 2 Limited Collision
Deductible
Enter deductible: The collision deductible amount.
COVERAGES PART 1-12
Auto 2 Limited Collision Premium
Amount
Enter amount: The collision premium amount.
COVERAGES PART 1-12
Auto 2 Comprehensive $100 Glass
Deductible
Check the box (if applicable): Indicates a $100 glass deductible applies to the
comprehensive coverage.
COVERAGES PART 1-12
Auto 2 Comprehensive Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES PART 1-12
Auto 2 Comprehensive Premium
Amount
Enter amount: The comprehensive or other than collision premium amount. In Texas this
is the comprehensive premium amount only.
COVERAGES PART 1-12
Auto 2 Substitute Transportation
Up To $ A Day
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES PART 1-12
Auto 2 Substitute Transportation $
Max
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES PART 1-12
Auto 2 Substitute Transportation
Premium Amount
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES PART 1-12
Auto 2 Towing and Labor Up to $
for each disablement
Enter limit: The towing and labor limit amount.
COVERAGES PART 1-12
Auto 2 Towing and Labor Premium
Amount
Enter amount: The towing and labor premium amount.
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
underinsured auto per person
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
underinsured auto per accident
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
COVERAGES PART 1-12
Auto 2 Bodily Injury caused by an
underinsured auto premium
amount
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount.
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Section Name
Field Name
Field and/or Section Description
COVERAGES PART 1-12
Auto 2 Safe Driver Insurance Plan
(SDIP) Premium Adjustment
Enter amount: The premium adjustment amount for the merit rating plan.
COVERAGES PART 1-12
Auto 2 Guest Occupant Exclusion
for Motorcycle Premium Amount
Enter amount: The guest occupant exclusion for motorcycles premium amount.
COVERAGES PART 1-12
Total Premium Amount
Enter amount: The estimated total cost amount of the policy.
VEHICLE INFORMATION
Auto 1 Principal Garaging
(City/Town & Zip)
Enter text: The vehicle's physical address line one.
VEHICLE INFORMATION
Enter text: The vehicle's physical address city name.
VEHICLE INFORMATION
Enter code: The vehicle's physical address postal code.
VEHICLE INFORMATION
Auto 2 Principal Garaging
(City/Town & Zip)
Enter text: The vehicle's physical address line one.
VEHICLE INFORMATION
Enter text: The vehicle's physical address city name.
VEHICLE INFORMATION
Enter code: The vehicle's physical address postal code.
VEHICLE INFORMATION
Vehicle Number
Enter number: The producer assigned vehicle number.
VEHICLE INFORMATION
Auto 1 Yr
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Auto 1 Make, Model and if
Motorcycle CC
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Enter number: The amount of horsepower or the number of cubic centimeters of
displacement.
VEHICLE INFORMATION
Auto 1 Vehicle Identification
Number
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE INFORMATION
Auto 1 Gross Veh Wt Rating for
van or pick-up
Enter number: The actual weight of the vehicle or the combined weight of tractor and
trailer in pounds.
VEHICLE INFORMATION
Auto 1 Registration Plate Number
Enter number: The license plate number.
VEHICLE INFORMATION
Auto 1 Date of Purchase
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE INFORMATION
Auto 1 Veh cost new motorcycle
avg retail value
Enter amount: The original cost of the vehicle.
VEHICLE INFORMATION
Auto 1 Miles Auto was driver in
past 12 mos.
Enter number: The total estimated annual mileage for the vehicle.
VEHICLE INFORMATION
Vehicle Number
Enter number: The producer assigned vehicle number.
VEHICLE INFORMATION
Auto 1 Odometer Reading
Enter number: The odometer reading at the time the insurance policy is applied for.
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Section Name
Field Name
Field and/or Section Description
VEHICLE INFORMATION
Auto 1 Air Bag/Passive Seat Belt
Yes/No
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 INFORMATION
Auto 1 Anti-theft Yes/No
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 INFORMATION
Auto 1 Vehicle Recovery System
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the vehicle is equipped
with an electronic recovery system.
VEHICLE INFORMATION
Auto 1 Leased Auto Yes/No
Enter Y for a Yes response. Input N for No response. Indicates if the vehicle is leased.
VEHICLE INFORMATION
Auto 1 Secured Lender And/Or
Lessor
Enter text: The additional interest's full name.
VEHICLE INFORMATION
Enter text: The additional interest's mailing address line one.
VEHICLE INFORMATION
Enter text: The additional interest's mailing address city name.
VEHICLE INFORMATION
Enter code: The additional interest's mailing address state or province code.
VEHICLE INFORMATION
Enter code: The additional interest's mailing address postal code.
VEHICLE INFORMATION
Vehicle Number
Enter number: The producer assigned vehicle number.
VEHICLE INFORMATION
Auto 2 Yr
Enter year: The model year of the vehicle.
VEHICLE INFORMATION
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE INFORMATION
Enter text: The manufacturer's model name for the vehicle.
VEHICLE INFORMATION
Auto 2 Make, Model and if
Motorcycle CC
Enter number: The amount of horsepower or the number of cubic centimeters of
displacement.
VEHICLE INFORMATION
Auto 2 Vehicle Identification
Number
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE INFORMATION
Auto 2 Gross Veh Wt Rating for
van or pick-up
Enter number: The actual weight of the vehicle or the combined weight of tractor and
trailer in pounds.
VEHICLE INFORMATION
Auto 2 Registration Plate Number
Enter number: The license plate number.
VEHICLE INFORMATION
Auto 2 Date of Purchase
Enter text: The month and year the applicant acquired the vehicle (MM/YYYY).
VEHICLE INFORMATION
Auto 2 Veh cost new motorcycle
avg retail value
Enter amount: The original cost of the vehicle.
VEHICLE INFORMATION
Auto 2 Miles Auto was driver in
past 12 mos.
Enter number: The total estimated annual mileage for the vehicle.
VEHICLE INFORMATION
Vehicle Number
Enter number: The producer assigned vehicle number.
VEHICLE INFORMATION
Auto 2 Odometer Reading
Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE INFORMATION
Auto 2 Air Bag/Passive Seat Belt
Yes/No
Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No
response to indicate airbags exists.
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Section Name
Field Name
Field and/or Section Description
VEHICLE INFORMATION
Auto 2 Anti-theft Yes/No
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 INFORMATION
Auto 2 Vehicle Recovery System
Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the vehicle is equipped
with an electronic recovery system.
VEHICLE INFORMATION
Auto 2 Leased Auto Yes/No
Enter Y for a Yes response. Input N for No response. Indicates if the vehicle is leased.
VEHICLE INFORMATION
Auto 2 Secured Lender And/Or
Lessor
Enter text: The additional interest's full name.
VEHICLE INFORMATION
Enter text: The additional interest's mailing address line one.
VEHICLE INFORMATION
Enter text: The additional interest's mailing address city name.
VEHICLE INFORMATION
Enter code: The additional interest's mailing address state or province code.
VEHICLE INFORMATION
Enter code: The additional interest's mailing address postal code.
DRIVER INFORMATION
Operator Number
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Current Driver's License # /
Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Merit Rating Points
Enter number: The merit rating points for the driver.
DRIVER INFORMATION
Date First Licensed Mass
Enter date: The original date on which a driver's license was issued to this driver in this
state.
DRIVER INFORMATION
Date First Licensed Other
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed Motorcycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Train Yes/No
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
% of Use Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
% of Use Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Operator Number
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Current Driver's License # /
Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Merit Rating Points
Enter number: The merit rating points for the driver.
DRIVER INFORMATION
Date First Licensed Mass
Enter date: The original date on which a driver's license was issued to this driver in this
state.
DRIVER INFORMATION
Date First Licensed Other
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed Motorcycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Train Yes/No
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
% of Use Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% of Use Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Operator Number
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Current Driver's License # /
Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Merit Rating Points
Enter number: The merit rating points for the driver.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Date First Licensed Mass
Enter date: The original date on which a driver's license was issued to this driver in this
state.
DRIVER INFORMATION
Date First Licensed Other
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed Motorcycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Train Yes/No
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
% of Use Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% of Use Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Operator Number
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Current Driver's License # /
Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Merit Rating Points
Enter number: The merit rating points for the driver.
DRIVER INFORMATION
Date First Licensed Mass
Enter date: The original date on which a driver's license was issued to this driver in this
state.
DRIVER INFORMATION
Date First Licensed Other
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed Motorcycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Train Yes/No
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 90 MA (2012/08) rev. 07-31-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
% of Use Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% of Use Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
A. Been involved in any motor
vehicle accident or been found
guilty of any moving violation? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been involved in any motor
vehicle accident or been found guilty of any moving violation?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been involved in any motor
vehicle accident or been found guilty of any moving violation?.
DRIVER INFORMATION
B. Been assigned to an alcohol
education program? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been assigned to an alcohol
education Program?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been assigned to an alcohol
education Program?.
DRIVER INFORMATION
C. Had two or more total fire or
total theft claims? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator had two or more total fire or total
theft losses?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator had two or more total fire or total
theft losses?.
DRIVER INFORMATION
D. Been convicted of vehicular
homicide, auto related fraud, auto
theft, or driving under the
influence of alcohol or drugs? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been convicted of vehicular
homicide, auto related fraud, auto theft, or driving under the influence of alcohol or
drugs?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been convicted of vehicular
homicide, auto related fraud, auto theft, or driving under the influence of alcohol or
drugs?.
DRIVER INFORMATION
E. Received payment from an
insurance company for any
comprehensive claim? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator received payment from an
insurance company for any collision or comprehensive loss including fire, theft, vandalism,
malicious mischief, or glass?.
ACORD 90 MA (2012/08) rev. 07-31-2012
12 of 16
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator received payment from an
insurance company for any collision or comprehensive loss including fire, theft, vandalism,
malicious mischief, or glass?.
DRIVER INFORMATION
F. Had your license revoked or
suspended? Yes
Check the box (if applicable): Indicates a Yes response to the question Any drivers
license been suspended/revoked?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question Any drivers
license been suspended/revoked?.
DRIVER INFORMATION
1. Do you presently owe any motor
vehicle premium, payable in the
last twelve months? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you
presently owe any motor vehicle premium, payable in the last twelve months?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Do you presently
owe any motor vehicle premium, payable in the last twelve months?.
DRIVER INFORMATION
2. Has any automobile insurance
policy been canceled or non-
renewed for any reason in the last
three (3) years? Yes
Check the box (if applicable): Indicates a Yes response to the question Any policy or
coverage declined, cancelled or non-renewed during the mandated number of years?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question Any policy or
coverage declined, cancelled or non-renewed during the mandated number of years?.
DRIVER INFORMATION
3. Are any listed operators
included on another policy or do
they have their own
Massachusetts personal
automobile policy? (List Operator
#, Insurance Company, and Policy
#)? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any listed
operators included on another policy or do they have their own MA personal automobile
policy?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Are any listed
operators included on another policy or do they have their own MA personal automobile
policy?.
ACORD 90 MA (2012/08) rev. 07-31-2012
13 of 16
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
4. If a vehicle is a motorcycle, has
the principal operator completed
an approved motorcycle rider
training program? (Attach Copy of
Certificate or Other Evidence of
Completion) Yes
Check the box (if applicable): Indicates a Yes response to the question, If a vehicle is a
motorcycle, has the principal operator completed an approved motorcycle rider training
Program?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, If a vehicle is a
motorcycle, has the principal operator completed an approved motorcycle rider training
Program?.
DRIVER INFORMATION
5. Is any auto used to transport (to
or from work or school): A. Fellow
employees, passengers or
students, for a fee? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used to transport (to or from work or school) fellow employees, passengers or students, for
a fee?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Is any auto used
to transport (to or from work or school) fellow employees, passengers or students, for a
fee?.
DRIVER INFORMATION
B. Persons employed by you? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used to transport (to or from work or school) persons employed by you?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Is any auto used
to transport (to or from work or school) persons employed by you?.
DRIVER INFORMATION
6. If any van or pick-up equipped
with custom furnishings or custom
equipment? (If Yes, you may wish
to purchase additional coverage).
Yes
Check the box (if applicable): Indicates a Yes response to the question Any vehicles
customized, altered or with special equipment?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question Any vehicles
customized, altered or with special equipment?.
DRIVER INFORMATION
7. Is any auto equipped with
electronic equipment permanently
installed but not in locations used
by the auto manufacturer for such
equipment?
Check the box (if applicable): Indicates a Yes response to the question, Any auto
equipped with electronic equipment permanently installed but not in locations used by the
auto manufacturer for such equipment?.
ACORD 90 MA (2012/08) rev. 07-31-2012
14 of 16
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Any auto
equipped with electronic equipment permanently installed but not in locations used by the
auto manufacturer for such equipment?.
DRIVER INFORMATION
8. Is any auto used in business?
(Type of Business) Yes
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used in business?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, Is any auto used
in business?.
DRIVER INFORMATION
A. If van/pick-up, is it used to
deliver/transport goods?
Check the box (if applicable): Indicates a Yes response to the question, If an auto used
in business is a van/pickup, is it used to deliver/transport goods?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, If an auto used in
business is a van/pickup, is it used to deliver/transport goods?.
DRIVER INFORMATION
B. Is gross vehicle weight 10,000
pounds or more? Yes
Check the box (if applicable): Indicates a Yes response to the question, If an auto used
in business, is gross vehicle weight 10,000 pounds or more?.
DRIVER INFORMATION
No
Check the box (if applicable): Indicates a No response to the question, If an auto used in
business, is gross vehicle weight 10,000 pounds or more?.
DRIVER INFORMATION
9. If any auto(s) to be insured is
titled with a salvage title issued by
the Mass registry of Motor
Vehicles, please indicate. (salvage
title vehicles are not eligible for
coverage parts 7, 8, or 9) Auto 1
Enter identifier: The salvage title number.
DRIVER INFORMATION
Auto 2
Enter identifier: The salvage title number.
DRIVER INFORMATION
11. Motorcycle Only, issue my
policy to expire at 12:01 AM on
January 1st and do not renew.
Check the box (if applicable): Indicates the response to the question, For motorcycles
only, do you want a policy issued to expire at 12:01 AM on January 1st and do not
renew?.
DRIVER INFORMATION
Trailer or recreational vehicle -
issue my policy to expire at 12:01
AM on December 1st and do not
renew.
Check the box (if applicable): Indicates the response to the question, For trailer or
recreational vehicles, do you want a policy issued to expire at 12:01 AM on December 1st
and do not renew?.
ATTACHMENTS
Anti-theft Device Certificate
Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft
device certificate.
ATTACHMENTS
Appraisal
Check the box (if applicable): Indicates if an attachment will follow containing an appraisal
form.
ATTACHMENTS
Approved driver training certificate
Check the box (if applicable): Indicates if an attachment will follow containing a driver
training certificate.
ACORD 90 MA (2012/08) rev. 07-31-2012
15 of 16
Section Name
Field Name
Field and/or Section Description
ATTACHMENTS
Approved motorcycle rider training
cert.
Check the box (if applicable): Indicates if an attachment will follow containing an approved
motorcycle rider training certificate.
ATTACHMENTS
Customized equipment evidence
Check the box (if applicable): Indicates if an attachment will follow containing customized
equipment evidence.
ATTACHMENTS
Operator Exclusion form
Check the box (if applicable): Indicates if an attachment will follow containing an operator
exclusion form.
ATTACHMENTS
Out-of-state driver record
Check the box (if applicable): Indicates if an attachment will follow containing an out of
state driving record.
ATTACHMENTS
Pre-Insurance form
Check the box (if applicable): Indicates if an attachment will follow containing a pre-
insurance form.
ATTACHMENTS
Vehicle Recovery System
Certificate
Check the box (if applicable): Indicates if an attachment will follow containing a vehicle
recovery system certificate.
REMARKS
Remarks
Enter text: The personal vehicle line of business remarks.
BINDER/SIGNATURE
Signature of Applicant
Sign here: Accommodates the signature of the applicant or named insured.
BINDER/SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
BINDER/SIGNATURE
Time
Enter time: The time the form was signed by the named insured.
BINDER/SIGNATURE
Signature of Agent
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.
BINDER/SIGNATURE
Date
Enter date: The date the producer signed the form.
BINDER/SIGNATURE
Time
Enter time: The time the producer signed the form.
BINDER/SIGNATURE
Applicant's Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
ACORD 90 MA (2012/08) rev. 07-31-2012
16 of 16