Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 103 (2012/03)
Personal Auto Application
Schedule - Additional Resident
and Driver Information Section
ACORD 103, Personal Auto Application Schedule - Additional
Resident and Driver Information Section, is used as an attachment to the ACORD
Personal Auto Application (90s), when more space is required for ADDITIONAL
RESIDENT AND DRIVER INFORMATION.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Page _
Enter number: The page number applicable to this page.
IDENTIFICATION SECTION
Of _
Enter number: The total number of pages applicable to this form.
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.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
ACORD 103 (2012/03) rev. 03-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
ACORD 103 (2012/03) rev. 03-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
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.
ACORD 103 (2012/03) rev. 03-30-2012
7 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
ACORD 103 (2012/03) rev. 03-30-2012
8 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
ACORD 103 (2012/03) rev. 03-30-2012
9 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
ACORD 103 (2012/03) rev. 03-30-2012
10 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
ACORD 103 (2012/03) rev. 03-30-2012
11 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
ACORD 103 (2012/03) rev. 03-30-2012
12 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
ACORD 103 (2012/03) rev. 03-30-2012
13 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
ACORD 103 (2012/03) rev. 03-30-2012
14 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
ACORD 103 (2012/03) rev. 03-30-2012
15 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
ACORD 103 (2012/03) rev. 03-30-2012
16 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
ACORD 103 (2012/03) rev. 03-30-2012
17 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
ACORD 103 (2012/03) rev. 03-30-2012
18 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
ACORD 103 (2012/03) rev. 03-30-2012
19 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
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.
ACORD 103 (2012/03) rev. 03-30-2012
20 of 25
Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
ACORD 103 (2012/03) rev. 03-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
ACORD 103 (2012/03) rev. 03-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
Number (#)
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name
Enter text: The driver's first name (given name).
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Relation to Applicant
Enter code: The relationship of the driver to the named insured. Examples are: I - Insured;
S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Occupation
Enter text: The occupation of the driver.
DRIVER INFORMATION
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
DRIVER INFORMATION
Stdt > 100
Enter Y for a Yes response. Input N for No response. Indicate if the driver resides at a
school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.
DRIVER INFORMATION
Good Stdt
Enter Y for a Yes response. Input N for No response. Indicate if the driver qualifies for a
good student credit (verify that company offers this credit). Complete and attach a Good
Student Certificate (ACORD 91) for each operator who qualifies.
ACORD 103 (2012/03) rev. 03-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Drv Train
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
Good Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a good driver credit (verify that company offers this credit). Attach a completion certificate
for each driver who qualifies.
DRIVER INFORMATION
Mat Drv
Enter Y for a Yes response. Input N for No response. Indicate if any driver qualifies for
a mature driver credit (verify that company offers this credit). Attach a completion
certificate for each driver who qualifies.
DRIVER INFORMATION
Acc Prev Cse
Enter date: The date on which the driver successfully completed an approved accident
prevention or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
DRIVER INFORMATION
Drivers License #/ Licensed State
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
REMARKS
Enter text: The remarks associated with a driver.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
ACORD 103 (2012/03) rev. 03-30-2012
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