ACORD 93 (2012/03)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 93 (2012/03)
Young Driver Questionnaire
ACORD 93, Young Driver Questionnaire, is generally completed by
drivers under the age of twenty five. The Young Driver Questionnaire provides additional
underwriting information that is usually common to youthful drivers. This form should be
completed and signed exclusively by the young driver with no input from the parents
and/or agent. The top section of the form must be completed by the young driver in
his/her own handwriting.
IMPORTANT: Question # 8 may not be asked in the District of Columbia, Missouri or
Ohio.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Driver #
Enter number: The number assigned to the driver by the producer.
IDENTIFICATION SECTION
Date (MM/DD/YYYY)
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
QUESTIONNAIRE
QUESTIONS
Do you have any driving
limitations imposed by your
parents?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you have any driving limitations imposed by your parents?.
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has ever had any driving
limitation imposed by parents.
QUESTIONNAIRE
QUESTIONS
Do you allow others to use your
car? (who and why)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you allow others to use your car?.
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Section Name
Field Name
Field and/or Section Description
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver allows other to use his or her
car.
QUESTIONNAIRE
QUESTIONS
Has your driver's license or permit
been revoked or suspended during
the last three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Has your driver's license or permit been revoked or suspended in the last
mandated number of years?.
QUESTIONNAIRE
QUESTIONS
Suspension Period - Start Date:
Enter date: The date the driver's license suspension became effective.
QUESTIONNAIRE
QUESTIONS
Suspension Period - End Date:
Enter date: The date the driver's license suspension is scheduled to end.
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has had his/her driver's license
or permit revoked or suspended during the last three (3) years.
QUESTIONNAIRE
QUESTIONS
Reinstatement Date
Enter date: The date a suspended or revoked driver's license was reinstated.
QUESTIONNAIRE
QUESTIONS
Have you received any traffic
violation*/conviction other than
parking? (*Not applicable in
Oregon)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you received any traffic violation*/conviction other than parking? (*Not
applicable in Oregon).
QUESTIONNAIRE
QUESTIONS
Date
Enter date: The date the driver received the traffic violation.
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has received any traffic
violation*/conviction other than parking? (*Not applicable in Oregon)
QUESTIONNAIRE
QUESTIONS
Have you had any accidents as a
driver? (During the last three (3)
years in Oregon)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you had any accidents as a driver? (During the last three (3) years in
Oregon)
QUESTIONNAIRE
QUESTIONS
Date
Enter date: The date of the accident.
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has had any accidents as a
driver.
QUESTIONNAIRE
QUESTIONS
Have you ever been arrested or
detained for any reason, other than
a traffic violation? (Not applicable
in Oregon)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have you ever been arrested or detained for any reason, other than a traffic
violation?.
QUESTIONNAIRE
QUESTIONS
Date
Enter date: The date the driver was arrested or detained for any reason other than a traffic
violation.
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Section Name
Field Name
Field and/or Section Description
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has ever been arrested or
detained for any reason other than a traffic violation.
QUESTIONNAIRE
QUESTIONS
Is the auto you operated modified
or equipped with any special
equipment, have modified
bodywork, or special paint?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the auto you operate modified or equipped with any special equipment, have
modified bodywork, or special paint?.
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver operates an auto that is modified
or equipped with any special equipment, bodywork or special paint.
QUESTIONNAIRE
QUESTIONS
Any auto insurance 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, Have you ever had auto insurance declined or cancelled? (Not applicable in the
District of Columbia, Missouri, or Ohio).
QUESTIONNAIRE
QUESTIONS
Explanation
Enter text: An explanation as to whether the young driver has had any auto insurance
declined, cancelled or non-renewed during the last three (3) years?
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Driver #
Enter number: The number assigned to the driver by the producer.
REMARKS
Remarks
Enter text: The producer's comments.
SIGNATURE
Young Driver's Signature
Sign here: Accommodates the signature of the driver.
SIGNATURE
Date
Enter date: The date the driver signed the form.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National
Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
state license number.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
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