ACORD 90 NY (2014/12) - NEW YORK PERSONAL AUTO APPLICATION

ACORD 90 NY (2014/12) - NEW YORK PERSONAL AUTO APPLICATION
ACORD 90 NY, New York Personal Auto Application, is used when insurance is desired for personal vehicles.
Following are the unique state characteristics of ACORD 90 NY, New York Personal Auto Application:
* Provision is made to report TAX TERRITORY
* A REGISTERED TO DRIVER # column is added to the VEHICLE DESCRIPTION / USE section to collect information as to which driver owns
each vehicle. This information is now required in NY state.
* Supplemental Spousal Liability Coverage is offered.
* Personal Injury Protection coverages are revised to reflect New York's unique coverages and options. Refer to your state Manual.
* COVERAGES / PREMIUMS section, a note states that a Motor Vehicle Law Enforcement Fee will be added to the total premium for each
vehicle.
* Time period for reporting ACCIDENTS / CONVICTIONS is 39 months.
* ADDITIONAL INTEREST Section has added check boxes for Owner, Lienholder and Registrant.
* A question has been added to the PRIOR COVERAGE Section regarding Assigned Risk
* GENERAL INFORMATION section, Question 1, relating to vehicle ownership, the name(s) that appear on the vehicle registration must be
provided. This information is required because New York DMV rules provide that the Named Insured in an auto policy must be the same as the
owner of the vehicle.
* Additional question in the GENERAL INFORMATION section regarding coverage by a Wage Continuation Plan.
* State specific Notice of Insurance Information Practices. Field added to insert name of Consumer Reporting Agency.
* Checkbox added to BINDER / SIGNATURE section acknowledging receipt of ACORD 38 NY, Notice of Insurance Information Practices by
applicant.
* Statement added to BINDER / SIGNATURE section acknowledging the explanation of Statutory Uninsured Motorists and Supplementary
Uninsured / Underinsured Motorists coverage to the applicant.
* Statement added to BINDER / SIGNATURE section acknowledging the explanation of Rental Vehicle Reimbursement coverage to the applicant.
* BINDER / SIGNATURE section, fraud warning specific to New York.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 1 of 44
Form Page 1
Section Name
Field Name
Description
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
Street One
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Street Two
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
City
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
State
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Zip + 4
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
Sub Code
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
Applicant's Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Address One
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Address Two
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
County
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Zip + 4
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION
Telephone Number
Enter number: The named insured's primary phone number.
ACORD 90 NY (2014/12) rev. 02-27-2014
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IDENTIFICATION SECTION
Tax Territory
Enter code: The city, county or state tax code.
IDENTIFICATION SECTION
Garaging Address check
box
Check the box (if applicable): Indicates the mailing address is the primary garaging address.
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. As used here, this may contain the name of the
residual market plan.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Plan
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION
Policy #
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
ACCT #
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
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
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
Mail Policy to Agent
Check the box (if applicable): Indicates if the policy paper should be sent to the producer.
IDENTIFICATION SECTION
Mail Policy to Applicant
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the
named insured.
IDENTIFICATION SECTION
Payment Plan
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
RESIDENCE
Owned
Check the box (if applicable): Indicates if the insured owns their current residence.
RESIDENCE
Rented
Check the box (if applicable): Indicates if the insured rents their current residence.
RESIDENCE
Number of Years at Current
Address
Enter number: The number of years at the current address.
RESIDENCE
Number of Years at
Previous Address
Enter number: The number of years at the previous address.
RESIDENCE
Previous Street Address
Enter text: The first address line of the previous residence address.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 3 of 44
RESIDENCE
Previous Street Address 2
Enter text: The second address line of the previous residence.
RESIDENCE
City
Enter text: The city of the previous residence.
RESIDENCE
State
Enter code: The state or province code of the previous residence.
RESIDENCE
Zip + 4
Enter text: The postal code of the previous residence.
ADDITIONAL GARAGING
ADDRESS(ES)
Location #
Enter number: The producer assigned number of the location.
ADDITIONAL GARAGING
ADDRESS(ES)
Street
Enter text: The first address line of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
City
Enter text: The city of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
County
Enter text: The county of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
State
Enter code: The state or province of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Zip + 4
Enter code: The postal code of the physical location. As used here, this is the garaging location
of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Tax Terr
Enter code: The city, county or state tax code.
ADDITIONAL GARAGING
ADDRESS(ES)
Location #
Enter number: The producer assigned number of the location.
ADDITIONAL GARAGING
ADDRESS(ES)
Street
Enter text: The first address line of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
City
Enter text: The city of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
County
Enter text: The county of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
State
Enter code: The state or province of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Zip + 4
Enter code: The postal code of the physical location. As used here, this is the garaging location
of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Tax Terr
Enter code: The city, county or state tax code.
ACORD 90 NY (2014/12) rev. 02-27-2014
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ADDITIONAL GARAGING
ADDRESS(ES)
Location #
Enter number: The producer assigned number of the location.
ADDITIONAL GARAGING
ADDRESS(ES)
Street
Enter text: The first address line of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
City
Enter text: The city of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
County
Enter text: The county of the physical location. As used here, this is the garaging location of the
vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
State
Enter code: The state or province of the physical location. As used here, this is the garaging
location of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Zip + 4
Enter code: The postal code of the physical location. As used here, this is the garaging location
of the vehicle.
ADDITIONAL GARAGING
ADDRESS(ES)
Tax Terr
Enter code: The city, county or state tax code.
VEHICLE DESCRIPTION /
USE
Total Number of Vehicles in
Household
Enter number: The total number of vehicles in the household.
VEHICLE DESCRIPTION /
USE
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
LOC # One
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
Registered State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Registered to Driver #
Enter number: The producer assigned driver number for whom the vehicle is registered.
ACORD 90 NY (2014/12) rev. 02-27-2014
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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
Miles 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
Carpool
Enter Y for a Yes response. Input N for No response. Indicates if a carpool discount applies.
ACORD 90 NY (2014/12) rev. 02-27-2014
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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 Number
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 Number
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 Number
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 Number
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 Number
Enter number: The producer assigned driver number of the driver using the vehicle.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 7 of 44
VEHICLE DESCRIPTION /
USE
Driver Use %
Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION /
USE
Driver Number
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 Drv/Both
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
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
Loc # Two
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 8 of 44
VEHICLE DESCRIPTION /
USE
Registered State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Registered to Driver #
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
Miles 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).
ACORD 90 NY (2014/12) rev. 02-27-2014
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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
Carpool
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.
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
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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 Drv/Both
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
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
Loc # Three
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
Registered State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Registered to Driver #
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).
ACORD 90 NY (2014/12) rev. 02-27-2014
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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
Miles 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
Carpool
Enter Y for a Yes response. Input N for No response. Indicates if a carpool discount applies.
ACORD 90 NY (2014/12) rev. 02-27-2014
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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.
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 13 of 44
VEHICLE DESCRIPTION /
USE
Air Bag Drv/Both
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
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE
Loc # Four
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
Registered State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION /
USE
Registered to Driver #
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 14 of 44
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
Miles 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
Carpool
Enter Y for a Yes response. Input N for No response. Indicates if a carpool discount applies.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 15 of 44
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.
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 16 of 44
VEHICLE DESCRIPTION /
USE
Air Bag Drv/Both
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.
COVERAGES / PREMIUMS
Vehicle Number One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Vehicle Number Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Vehicle Number Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Vehicle Number Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Single Limit Liability CSL
Each 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).
COVERAGES / PREMIUMS
Single Limit Liability
Amount One
Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS
Single Limit Liability
Amount Two
Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS
Single Limit Liability
Amount Three
Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS
Single Limit Liability
Amount Four
Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS
Bodily Injury Each 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).
COVERAGES / PREMIUMS
Bodily Injury Each 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).
COVERAGES / PREMIUMS
Bodily Injury Amount One
Enter amount: The vehicle policy, bodily injury premium amount.
COVERAGES / PREMIUMS
Bodily Injury Amount Two
Enter amount: The vehicle policy, bodily injury premium amount.
COVERAGES / PREMIUMS
Bodily Injury Amount Three
Enter amount: The vehicle policy, bodily injury premium amount.
COVERAGES / PREMIUMS
Bodily Injury Amount Four
Enter amount: The vehicle policy, bodily injury premium amount.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 17 of 44
COVERAGES / PREMIUMS
Property Damage Each
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 / PREMIUMS
Property Damage Amount
Vehicle One
Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS
Property Damage Amount
Vehicle Two
Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS
Property Damage Amount
Vehicle Three
Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS
Property Damage Amount
Vehicle Four
Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Included
Check the box (if applicable): Indicates supplemental spousal liability coverage is included.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Not Included
Check the box (if applicable): Indicates supplemental spousal liability coverage is not included.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Amount Vehicle
One
Enter amount: The supplemental spousal liability premium amount.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Amount Vehicle
Two
Enter amount: The supplemental spousal liability premium amount.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Amount Vehicle
Three
Enter amount: The supplemental spousal liability premium amount.
COVERAGES / PREMIUMS
Supplemental Spousal
Liability Amount Vehicle
Four
Enter amount: The supplemental spousal liability premium amount.
COVERAGES / PREMIUMS
Personal Inj Protection
Amount
Enter limit: The personal injury protection (PIP) limit amount.
COVERAGES / PREMIUMS
Personal Inj Protection
Deductible
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
COVERAGES / PREMIUMS
Work Loss Coordination Y /
N
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has personal injury protection (PIP) work loss coordination option has been selected?
COVERAGES / PREMIUMS
Medical Expense
Elimination Named Insured
Only
Check the box (if applicable): Indicates the personal injury protection (PIP) medical expense
option has been selected for the named insured only.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 18 of 44
COVERAGES / PREMIUMS
Medical Expense
Elimination Named Insured
and Relatives
Check the box (if applicable): Indicates the personal injury protection (PIP) medical expense
option has been selected for the named insured and relatives.
COVERAGES / PREMIUMS
Personal Inj Protection
Amount Vehicle One
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES / PREMIUMS
Personal Inj Protection
Amount Vehicle Two
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES / PREMIUMS
Personal Inj Protection
Amount Vehicle Three
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES / PREMIUMS
Personal Inj Protection
Amount Vehicle Four
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Amount
Enter limit: The additional personal injury protection (APIP) limit amount.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Work Loss
Amount
Enter limit: The additional personal injury protection (APIP) work/wage loss limit amount.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Other Exp
Amount
Enter limit: The limit amount for the other expense coverage.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Death Benefits
Amount
Enter limit: The additional personal injury protection (APIP) accidental death benefit limit
amount.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Amount Vehicle
One
Enter amount: The premium associated with additional personal injury protection (APIP)
coverage.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Amount Vehicle
Two
Enter amount: The premium associated with additional personal injury protection (APIP)
coverage.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Amount Vehicle
Three
Enter amount: The premium associated with additional personal injury protection (APIP)
coverage.
COVERAGES / PREMIUMS
Additional Personal Inj
Protection Amount Vehicle
Four
Enter amount: The premium associated with additional personal injury protection (APIP)
coverage.
COVERAGES / PREMIUMS
OBEL
Enter limit: The limit amount for the optional basic economic loss coverage.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 19 of 44
COVERAGES / PREMIUMS
OBEL Amount Vehicle One
Enter amount: The premium amount for the optional basic economic loss coverage.
COVERAGES / PREMIUMS
OBEL Amount Vehicle Two
Enter amount: The premium amount for the optional basic economic loss coverage.
COVERAGES / PREMIUMS
OBEL Amount Vehicle Three
Enter amount: The premium amount for the optional basic economic loss coverage.
COVERAGES / PREMIUMS
OBEL Amount Vehicle Four
Enter amount: The premium amount for the optional basic economic loss coverage.
COVERAGES / PREMIUMS
Medical Payments Each
Person
Enter limit: The medical payments per person limit.
COVERAGES / PREMIUMS
Medical Payments Amount
Vehicle One
Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS
Medical Payments Amount
Vehicle Two
Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS
Medical Payments Amount
Vehicle Three
Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS
Medical Payments Amount
Vehicle Four
Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS
Statutory UM BI Each
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 / PREMIUMS
Statutory UM BI Each
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 / PREMIUMS
Statutory UM BI Amount
Vehicle One
Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS
Statutory UM BI Amount
Vehicle Two
Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS
Statutory UM BI Amount
Vehicle Three
Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS
Statutory UM BI Amount
Vehicle Four
Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Each Person
Enter limit: The per person limit amount for the supplementary uninsured / underinsured
motorists coverage.
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Each Accident
Enter limit: The per accident limit amount for the supplementary uninsured / underinsured
motorists coverage.
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Amount Vehicle One
Enter amount: The premium amount for the supplementary uninsured / underinsured motorists
coverage.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 20 of 44
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Amount Vehicle Two
Enter amount: The premium amount for the supplementary uninsured / underinsured motorists
coverage.
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Amount Vehicle
Three
Enter amount: The premium amount for the supplementary uninsured / underinsured motorists
coverage.
COVERAGES / PREMIUMS
Supplementary UM/UIM
(SUM) Amount Vehicle Four
Enter amount: The premium amount for the supplementary uninsured / underinsured motorists
coverage.
COVERAGES / PREMIUMS
Comprehensive / OTC
Vehicle Number One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount One
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS
Comprehensive / OTC Full
Glass One
Check the box (if applicable): Indicates the full glass option applies to the comprehensive/other
than collision coverage.
COVERAGES / PREMIUMS
Comprehensive / OTC
Vehicle Number Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Two
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS
Comprehensive / OTC Full
Glass Two
Check the box (if applicable): Indicates the full glass option applies to the comprehensive/other
than collision coverage.
COVERAGES / PREMIUMS
Comprehensive / OTC
Vehicle Number Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Three
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS
Comprehensive / OTC Full
Glass Three
Check the box (if applicable): Indicates the full glass option applies to the comprehensive/other
than collision coverage.
COVERAGES / PREMIUMS
Comprehensive / OTC
Vehicle Number Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Four
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS
Comprehensive / OTC Full
Glass Four
Check the box (if applicable): Indicates the full glass option applies to the comprehensive/other
than collision coverage.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Vehicle One
Enter amount: The comprehensive or other than collision premium amount.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 21 of 44
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Vehicle Two
Enter amount: The comprehensive or other than collision premium amount.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Vehicle Three
Enter amount: The comprehensive or other than collision premium amount.
COVERAGES / PREMIUMS
Comprehensive / OTC
Amount Vehicle Four
Enter amount: The comprehensive or other than collision premium amount.
COVERAGES / PREMIUMS
Collision Vehicle Number
One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Collision Amount One
Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS
Collision Full Glass One
Check the box (if applicable): Indicates the full glass option applies to the collision coverage.
COVERAGES / PREMIUMS
Collision Vehicle Number
Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Collision Amount Two
Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS
Collision Full Glass Two
Check the box (if applicable): Indicates the full glass option applies to the collision coverage.
COVERAGES / PREMIUMS
Collision Vehicle Number
Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Collision Amount Three
Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS
Collision Full Glass Three
Check the box (if applicable): Indicates the full glass option applies to the collision coverage.
COVERAGES / PREMIUMS
Collision Vehicle Number
Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Collision Amount Four
Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS
Collision Full Glass Four
Check the box (if applicable): Indicates the full glass option applies to the collision coverage.
COVERAGES / PREMIUMS
Collision Amount Vehicle
One
Enter amount: The collision premium amount.
COVERAGES / PREMIUMS
Collision Amount Vehicle
Two
Enter amount: The collision premium amount.
COVERAGES / PREMIUMS
Collision Amount Vehicle
Three
Enter amount: The collision premium amount.
COVERAGES / PREMIUMS
Collision Amount Vehicle
Four
Enter amount: The collision premium amount.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 22 of 44
COVERAGES / PREMIUMS
ACV unless Amount Stated
Vehicle Number One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Amount One
Enter limit: The limit associated with comprehensive and collision coverage is the actual cash
value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Vehicle Number Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Amount Two
Enter limit: The limit associated with comprehensive and collision coverage is the actual cash
value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Vehicle Number Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Amount Three
Enter limit: The limit associated with comprehensive and collision coverage is the actual cash
value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Vehicle Number Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
ACV unless Amount Stated
Amount Four
Enter limit: The limit associated with comprehensive and collision coverage is the actual cash
value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS
Towing & Labor Vehicle
Number One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Towing & Labor Amount
One
Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS
Towing & Labor Vehicle
Number Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Towing & Labor Amount
Two
Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS
Towing & Labor Vehicle
Number Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Towing & Labor Amount
Three
Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS
Towing & Labor Vehicle
Number Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Towing & Labor Amount
Four
Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS
Towing & Labor Amount
Vehicle One
Enter amount: The towing and labor premium amount.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 23 of 44
COVERAGES / PREMIUMS
Towing & Labor Amount
Vehicle Two
Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS
Towing & Labor Amount
Vehicle Three
Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS
Towing & Labor Amount
Vehicle Four
Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Vehicle Number One
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Transportation Expense Per
Day Limit One
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS
Transportation Expense
Maximum Limit One
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Vehicle Number Two
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Transportation Expense Per
Day Limit Two
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS
Transportation Expense
Maximum Limit Two
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Vehicle Number Three
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Transportation Expense Per
Day Limit Three
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS
Transportation Expense
Maximum Limit Three
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Vehicle Number Four
Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS
Transportation Expense Per
Day Limit Four
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS
Transportation Expense
Maximum Limit Four
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 24 of 44
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Amount Vehicle One
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Amount Vehicle Two
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Amount Vehicle Three
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS
Transportation Expenses
And Rental Reimbursement
Amount Vehicle Four
Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS
Coverage Code
Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS
Description
Enter text: The description of the coverage.
COVERAGES / PREMIUMS
Limit
Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS
Limit Applies To
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS
Limit
Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS
Limit Applies To
Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS
Deductible $
Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS
Deductible %
Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS
Option 1
Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS
Option 2
Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS
Option 3
Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS
Option 4
Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS
Amount
Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS
Amount
Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS
Amount
Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS
Amount
Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS
Estimated Total
Enter amount: The estimated total cost amount of the policy.
COVERAGES / PREMIUMS
Policy Fee
Enter amount: The amount of fee associated with the policy.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 25 of 44
COVERAGES / PREMIUMS
Total Per Vehicle
Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS
Total Per Vehicle
Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS
Total Per Vehicle
Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS
Total Per Vehicle
Enter amount: The total amount for the vehicle.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 26 of 44
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 27 of 44
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 28 of 44
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 29 of 44
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 30 of 44
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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 90 NY (2014/12) rev. 02-27-2014
Page 31 of 44
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
First Name
Enter text: The driver's first name (given name).
RESIDENT & DRIVER
INFORMATION
Middle Name
Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER
INFORMATION
Last Name
Enter text: The driver's last name (surname).
RESIDENT & DRIVER
INFORMATION
Sex
Enter code: The gender of the driver.
RESIDENT & 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
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Date of Birth
Enter date: The birth date of the driver.
RESIDENT & DRIVER
INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER
INFORMATION
Occupation
Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & 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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 32 of 44
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & 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.
RESIDENT & DRIVER
INFORMATION
Drivers License #
Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION
Licensed State
Enter code: The state in which the driver is licensed.
RESIDENT & DRIVER
INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
ACCIDENTS / CONVICTIONS 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, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI 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, may be attached if more space is needed.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 33 of 44
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI 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, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI 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, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI 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, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 34 of 44
ACCIDENTS / CONVICTIONS BI 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.
ADDITIONAL INTEREST
Additional Insured One
Check the box (if applicable): Indicates the interest type is an additional interest.
ADDITIONAL INTEREST
Loss Payee One
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Owner One
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST
Lender's Loss Payable One
Check the box (if applicable): Indicates the additional interest type is a lenders loss payable.
ADDITIONAL INTEREST
Lienholder One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Registrant One
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST
Other Additional Interest
One
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
ADDITIONAL INTEREST
Describe Other Additional
Interest One
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Street
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
City
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
State
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Zip + 4
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Veh # One
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Loan Number One
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Additional Insured Two
Check the box (if applicable): Indicates the interest type is an additional interest.
ADDITIONAL INTEREST
Loss Payee Two
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Owner Two
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST
Lender's Loss Payable Two
Check the box (if applicable): Indicates the additional interest type is a lenders loss payable.
ADDITIONAL INTEREST
Lienholder Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Registrant Two
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST
Other Additional Interest
Two
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 35 of 44
ADDITIONAL INTEREST
Describe Other Additional
Interest Two
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Street
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
City
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
State
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Zip + 4
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Veh # Two
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Loan Number Two
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
EMPLOYMENT
INFORMATION
Applicant's Employer
Enter text: The employer name (business name if self-employed).
EMPLOYMENT
INFORMATION
Address of Employment
Enter text: The first address line of the employer's physical address.
EMPLOYMENT
INFORMATION
City
Enter text: The city of the employer's physical address.
EMPLOYMENT
INFORMATION
State
Enter code: The state code of the employer's physical address.
EMPLOYMENT
INFORMATION
Zip + 4
Enter code: The postal code of the employer's physical address.
EMPLOYMENT
INFORMATION
Work Phone Number
Enter number: The phone number of the employer.
EMPLOYMENT
INFORMATION
Years With Current
Employer
Enter number: The number of years the named insured has been with their current employer.
EMPLOYMENT
INFORMATION
Years With Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
EMPLOYMENT
INFORMATION
Co-Applicant's Employer
Enter text: The employer name (business name if self-employed).
EMPLOYMENT
INFORMATION
Address of Employment
Enter text: The first address line of the employer's physical address.
EMPLOYMENT
INFORMATION
City
Enter text: The city of the employer's physical address.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 36 of 44
EMPLOYMENT
INFORMATION
State
Enter code: The state code of the employer's physical address.
EMPLOYMENT
INFORMATION
Zip + 4
Enter code: The postal code of the employer's physical address.
EMPLOYMENT
INFORMATION
Work Phone Number
Enter number: The phone number of the employer.
EMPLOYMENT
INFORMATION
Years With Current
Employer
Enter number: The number of years the named insured has been with their current employer.
EMPLOYMENT
INFORMATION
Years With Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
# of Years With Company
Enter number: The number of years with the previous insurer.
PRIOR COVERAGE
Assigned Risk Y / N
Enter Y for a Yes response. Input N for No response. Indicates the prior coverage was an
assigned risk policy.
PRIOR COVERAGE
Prior Producer
Enter text: The name of the previous producer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
GENERAL INFORMATION
1. With the exception of any
encumbrances, are any
vehicles for which
insurance is requested 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. As used here, this is the name of the other owner
of the vehicle.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Name of Other Owner
Enter text: The additional interest's full name. As used here, this is the name of the other owner
of the vehicle.
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 37 of 44
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?
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.
GENERAL INFORMATION
4. Any other losses not
shown in the Accidents /
Convictions section that
were incurred during the
time period specified in that
section?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Any losses not shown in the Accidents / Convictions section that were incurred during the time
period specified in that section?.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Description
Enter text: The description of any other losses incurred.
GENERAL INFORMATION
Cost
Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Description
Enter text: The description of any other losses incurred.
GENERAL INFORMATION
Cost
Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION
5. Any other automobile
insurance?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Any other auto insurance in household? (Include any provided by employer).
GENERAL INFORMATION
Name Insured
Enter text: The named insured on other insurance.
GENERAL INFORMATION
Year
Enter year: The model year of the vehicle. As used here, this is a vehicle covered by other
insurance.
GENERAL INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy). As used here, this is a vehicle
covered by other insurance.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 38 of 44
GENERAL INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle. As used here, this is a vehicle
covered by other insurance.
GENERAL INFORMATION
Carrier
Enter text: The insurer name on any other applicable insurance.
GENERAL INFORMATION
NAIC #
Enter code: The NAIC code of the insurance company that issued the policy.
GENERAL INFORMATION
Policy #
Enter identifier: The policy number on any other applicable insurance.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
GENERAL INFORMATION
(continued)
6. Any other insurance with
this company?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any other insurance with this company?.
GENERAL INFORMATION
(continued)
Policy Number One
Enter identifier: The policy number on any other applicable insurance.
GENERAL INFORMATION
(continued)
Type of Insurance One
Enter code: The line of business of the other policy.
GENERAL INFORMATION
(continued)
Policy Number Two
Enter identifier: The policy number on any other applicable insurance.
GENERAL INFORMATION
(continued)
Type of Insurance Two
Enter code: The line of business of the other policy.
GENERAL INFORMATION
(continued)
7. 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
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(continued)
Branch
Enter text: The branch of military service.
GENERAL INFORMATION
(continued)
Rank
Enter text: The driver's rank in the military.
GENERAL INFORMATION
(continued)
Base Location
Enter text: The military base's first address line.
GENERAL INFORMATION
(continued)
City
Enter text: The city of the military base.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 39 of 44
GENERAL INFORMATION
(continued)
State
Enter code: The state or province code of the military base.
GENERAL INFORMATION
(continued)
Zip
Enter code: The postal code of the military base.
GENERAL INFORMATION
(continued)
Country
Enter code: The country code of the military base.
GENERAL INFORMATION
(continued)
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
(continued)
8. Any license 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
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(continued)
Suspension Period - Start
Date:
Enter date: The date the driver's license suspension became effective.
GENERAL INFORMATION
(continued)
Suspension Period - End
Date:
Enter date: The date the driver's license suspension is scheduled to end.
GENERAL INFORMATION
(continued)
Explanation
Enter text: The reason the driver's license was suspended or revoked.
GENERAL INFORMATION
(continued)
Reinstatement Date
Enter date: The date a suspended or revoked driver's license was reinstated.
GENERAL INFORMATION
(continued)
9. Any driver have physical
impairment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Any driver have a physical impairment that would affect the ability to drive?.
GENERAL INFORMATION
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(continued)
Description of Special
Equipment in Vehicle
Enter text: The description of any special equipment.
GENERAL INFORMATION
(continued)
10. 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 that
would affect the ability to drive?.
GENERAL INFORMATION
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(continued)
Explanation
Enter text: The description of any medication or treatments for a driver with physical or mental
impairments.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 40 of 44
GENERAL INFORMATION
(continued)
11. 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?.
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)
12. Has insurance been
transferred within agency?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has insurance been transferred within agency?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of insurance transferred within the agency.
GENERAL INFORMATION
(continued)
13. 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.
GENERAL INFORMATION
(continued)
14. Is this brokered
business to the agent?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Is this brokered business to the agent?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation of brokered business to the agent.
GENERAL INFORMATION
(continued)
15. Has Agent Inspected
Vehicle?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Has agent inspected vehicle?.
GENERAL INFORMATION
(continued)
Remarks
Enter text: An explanation indicating if agent has inspected vehicle.
GENERAL INFORMATION
(continued)
16. Has any applicant or
driver had a foreclosure,
repossession, bankruptcy,
judgement or lien during the
last five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question
Has any applicant or driver had a foreclosure, repossession, bankruptcy, judgment or lien
during the last specified number of years?.
GENERAL INFORMATION
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 41 of 44
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any applicant or driver who has had a foreclosure, repossession,
bankruptcy, judgment or lien during the last mandated number of years.
GENERAL INFORMATION
(continued)
17. Has any named insured
driven without liability
insurance during any part of
the last six (6) months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any named insured driven without liability insurance during any part of the last six (6)
months?.
GENERAL INFORMATION
(continued)
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
(continued)
Explanation
Enter text: The explanation of why the driver has driven without liability insurance during any part
of the last six (6) months.
GENERAL INFORMATION
(continued)
18. Any applicant covered
by a wage continuation
plan?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any applicant covered by a wage continuation plan?
GENERAL INFORMATION
(continued)
Name of Plan
Enter text: The name of the wage continuation plan.
GENERAL INFORMATION
(continued)
Person Covered
Enter text: The name of any person covered by a wage continuation plan.
GENERAL INFORMATION
(continued)
Name of Plan
Enter text: The name of the wage continuation plan.
GENERAL INFORMATION
(continued)
Person Covered
Enter text: The name of any person covered by a wage continuation plan.
REMARKS / ATTACHMENTS Young Driver Questionnaire
Check the box (if applicable): Indicates if an attachment will follow containing a young driver
questionnaire.
REMARKS / ATTACHMENTS Driver Training Certificate
Check the box (if applicable): Indicates if an attachment will follow containing a driver training
certificate.
REMARKS / ATTACHMENTS Good Student Certificate
Check the box (if applicable): Indicates if an attachment will follow containing a good student
certificate.
REMARKS / ATTACHMENTS Anti-Theft Device Certificate
Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft
device certificate.
REMARKS / ATTACHMENTS Medical Statement
Check the box (if applicable): Indicates if an attachment will follow containing a medical
statement.
REMARKS / ATTACHMENTS Motor Vehicle Report
Check the box (if applicable): Indicates if an attachment will follow containing a motor vehicle
report.
REMARKS / ATTACHMENTS Photograph
Check the box (if applicable): Indicates if an attachment will follow containing a photograph.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 42 of 44
REMARKS / ATTACHMENTS Bill of Sale
Check the box (if applicable): Indicates if an attachment will follow containing a bill of sale.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Remarks
Enter text: The personal vehicle line of business remarks.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
REMARKS
Remarks
Enter text: The personal vehicle line of business remarks.
BINDER / SIGNATURE
Effective Date
Enter date: The date on which the terms and conditions of the binder commenced. This date
normally coincides with the effective date of the policy or of an endorsement to the policy.
BINDER / SIGNATURE
Time
Enter time: The time of the binder effective date that the binder becomes effective.
BINDER / SIGNATURE
Expiration Date
Enter date: The date on which the terms and conditions of the policy will or have expired.
Certain state laws limit the terms of a binder, so this date may not coincide with the policy
expiration date.
BINDER / SIGNATURE
12:01
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
BINDER / SIGNATURE
Noon
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
BINDER / SIGNATURE
Coverage Not Bound
Check the box (if applicable): Indicates the coverage has not been bound.
BINDER / SIGNATURE
ACORD 38 NY check box
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
BINDER / SIGNATURE
Producer's Statement
Enter text: The length of time the named insured has been known by the producer.
BINDER / SIGNATURE
Applicant's Signature
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.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 43 of 44
BINDER / SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
BINDER / 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.
APPLICANT/NAMED
INSURED'S SIGNATURE
Consumer Reporting
Agency
Enter text: The code identifies an external source that may be used to provide financial or credit
information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union,
etc.
ACORD 90 NY (2014/12) rev. 02-27-2014
Page 44 of 44