ACORD 127 (2014/12) - BUSINESS AUTO SECTION
ACORD 127 (2014/12) - BUSINESS AUTO SECTION
ACORD 127, Business Auto Section, of the ACORD Commercial Insurance Application series, contains basic policy information as well as
essential underwriting information for commercial auto accounts. Through the effective use of the Business Auto Section, specific needs of an
individual account can be addressed. Space is provided to enter driver information for up to thirteen drivers. For additional drivers, ACORD 163,
Driver Information Schedule, can be attached. Space is also provided to enter descriptions of up to four vehicles. If the fleet should exceed this
number, ACORD 129, Vehicle Schedule, which contains space for 5 additional vehicles, can be attached.
Form Page 1
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).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
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. (MM/DD/YYYY)
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
ACORD 163 Attached
Check the box (if applicable): Indicates that additional drivers appear on the attached ACORD
163 Commercial Auto Driver Information Schedule.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
ACORD 127 (2014/12) rev. 04-29-2014
Page 1 of 32
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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 127 (2014/12) rev. 04-29-2014
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DRIVER INFORMATION
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
ACORD 127 (2014/12) rev. 04-29-2014
Page 3 of 32
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
ACORD 127 (2014/12) rev. 04-29-2014
Page 4 of 32
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
ACORD 127 (2014/12) rev. 04-29-2014
Page 5 of 32
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
ACORD 127 (2014/12) rev. 04-29-2014
Page 6 of 32
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
ACORD 127 (2014/12) rev. 04-29-2014
Page 7 of 32
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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 127 (2014/12) rev. 04-29-2014
Page 8 of 32
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
ACORD 127 (2014/12) rev. 04-29-2014
Page 9 of 32
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
ACORD 127 (2014/12) rev. 04-29-2014
Page 10 of 32
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
ACORD 127 (2014/12) rev. 04-29-2014
Page 11 of 32
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver #
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
Enter text: The city of the driver.
DRIVER INFORMATION
Enter code: The state or province of the driver.
DRIVER INFORMATION
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital 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
Date of Birth
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed
Enter year: The original year in which a driver's license was issued to this driver.
ACORD 127 (2014/12) rev. 04-29-2014
Page 12 of 32
DRIVER INFORMATION
Driver's License Number /
Social Security Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Enter identifier: The tax identifier (social security number) of the driver. As used here, only enter
the social security number if the drivers license number is unavailable.
DRIVER INFORMATION
State Lic.
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broadened No Fault
Enter Y for a Yes response. Input N for No response. Indicates if broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC
Enter Y for a Yes response. Input N for No response. Indicates if driver is covered by Drive
Other Car coverage.
DRIVER INFORMATION
Use Vehicle #
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
GENERAL INFORMATION
1. With the exception of
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 encumbrances, are any vehicles not solely owned by and registered to
the application?.
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. Do over 50% of the
employees use their autos
in the business?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do over 50% of the employees use their own autos in the business?.
GENERAL INFORMATION
3. Is there a vehicle
maintenance program in
operation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a vehicle maintenance program in operation?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of any vehicle maintenance program in operation.
GENERAL INFORMATION
4. Are any vehicles leased to
others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any vehicles leased to others?.
ACORD 127 (2014/12) rev. 04-29-2014
Page 13 of 32
GENERAL INFORMATION
Explanation
Enter text: An explanation of any vehicles leased to others.
GENERAL INFORMATION
5. Any car modified / special
equipment? (Include
customized vans / pickups)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any vehicle customized, altered or have special equipment?.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Description
Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION
Cost
Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION
Veh #
Enter number: The producer assigned vehicle number.
GENERAL INFORMATION
Description
Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION
Cost
Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION
6. Are ICC (Interstate
Commerce Commission),
PUC (Public Utility
Commission) or other filings
required? (If YES, attach
ACORD 194)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are ICC, PUC or other filings required?.
GENERAL INFORMATION
7. Do operations involve
transporting hazardous
material?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do operations involve transporting hazardous material?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of any operations that involve transporting hazardous materials..
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).
GENERAL INFORMATION
(continued)
8. Any Hold Harmless
Agreements?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any hold harmless agreements?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any Hold Harmless Agreements.
GENERAL INFORMATION
(continued)
9. Any vehicles used by
family members?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any vehicles used by family members?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any vehicles used by family members.
ACORD 127 (2014/12) rev. 04-29-2014
Page 14 of 32
GENERAL INFORMATION
(continued)
10. Does the applicant
obtain MVR (Motor Vehicle
Record) verifications?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant obtain MVR verifications?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any applicant needing to obtain MVR verifications.
GENERAL INFORMATION
(continued)
11. Does the applicant have
a specific driver recruiting
method?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have a specific driver recruiting method?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any applicant specific driver recruiting methods.
GENERAL INFORMATION
(continued)
12. Are any drivers not
covered by Workers
Compensation?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any drivers not covered by workers compensation?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any drivers not covered by workers compensation.
GENERAL INFORMATION
(continued)
13. Any vehicles owned but
not scheduled on this
application?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any vehicles owned but not scheduled on this application?.
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any vehicles owned but not scheduled on this application.
GENERAL INFORMATION
(continued)
14. Any drivers with
convictions for moving
traffic violations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any drivers with convictions for moving traffic violations?.
GENERAL INFORMATION
(continued)
Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
GENERAL INFORMATION
(continued)
Date (MM/DD/YYYY)
Enter date: The date the driver received the traffic violation.
GENERAL INFORMATION
(continued)
Type
Enter text: The description of the traffic violation. ACORD 101, Additional Remarks Schedule,
may be attached if more space is required.
GENERAL INFORMATION
(continued)
Place (City, State)
Enter text: The place of the accident or conviction.
GENERAL INFORMATION
(continued)
# Yrs Rev
Enter number: The number of years associated with an accident... or convicted of a moving
violation question.
GENERAL INFORMATION
(continued)
15. Has agent inspected
vehicles?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has agent inspected vehicles?.
ACORD 127 (2014/12) rev. 04-29-2014
Page 15 of 32
GENERAL INFORMATION
(continued)
Explanation
Enter text: An explanation of any vehicles inspected by an agent.
GENERAL INFORMATION
(continued)
16. Are all vehicles to be
included in this policy part
of a fleet? Y / N
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all vehicles to be included in this policy part of a fleet?.
GENERAL INFORMATION
(continued)
17. Do you have electronic
monitoring devices that
record and transmit data in
any of your vehicles?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have electronic monitoring devices that record and transmit data in any of your
vehicles.
GENERAL INFORMATION
(continued)
Percentage of vehicles in
overall fleet that are
monitored (%)
Enter percentage: The percentage of vehicles in your overall fleet that are monitored.
GENERAL INFORMATION
(continued)
Monitor Driver Safety
(checkbox)
Check the box (if applicable): Indicates that driver safety is monitored.
GENERAL INFORMATION
(continued)
Track Fuel Consumption
(checkbox)
Check the box (if applicable): Indicates that a track fuel consumption device is utilized.
GENERAL INFORMATION
(continued)
Monitor Vehicle
Maintenance (checkbox)
Check the box (if applicable): Indicates that a vehicle maintenance monitor device is utilized.
GENERAL INFORMATION
(continued)
Mileage Tracking
(checkbox)
Check the box (if applicable): Indicates that a mileage tracking device is utilized.
GENERAL INFORMATION
(continued)
Location Tracking
(checkbox)
Check the box (if applicable): Indicates that a location tracking device is utilized.
GENERAL INFORMATION
(continued)
Navigation (checkbox)
Check the box (if applicable): Indicates that a navigation device is utilized.
GENERAL INFORMATION
(continued)
Other Electronic Monitoring
Device (checkbox)
Check the box (if applicable): Indicates that an electronic data monitoring device other than
those listed is utilized.
GENERAL INFORMATION
(continued)
Description of Other
Electronic Monitoring
Device
Enter text: The name of the other electronic tracking device.
GENERAL INFORMATION
(continued)
Describe:
Enter text: Provide additional information clarifying the general use of electronic monitoring
devices.
GENERAL INFORMATION
(continued)
Description of Garage /
Storage Locations
Enter text: The description of the garage / storage location.
GENERAL INFORMATION
(continued)
Maximum Dollar Value
Subject to Loss
Enter amount: The highest value that the insurer would be subject to if a major automobile loss
occurred on the insured premises.
ACORD 127 (2014/12) rev. 04-29-2014
Page 16 of 32
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
ACORD 45 Attached
Check the box (if applicable): Indicates that further additional interests appear on the attached
ACORD 45.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Additional Interest
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Additional Interest
Description
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Owner
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Registrant
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Interest Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ACORD 127 (2014/12) rev. 04-29-2014
Page 17 of 32
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest in Item Number
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest in Item Number
Location Number
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Additional Interest
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Additional Interest
Description
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Owner
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest Registrant
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Interest Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address postal code.
ACORD 127 (2014/12) rev. 04-29-2014
Page 18 of 32
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest in Item Number
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest in Item Number
Location Number
Enter number: The producer assigned number of the location which has an additional interest.
REMARKS
Remarks
Enter text: The remarks associated with the commercial vehicle line of business. Enter any
endorsements that apply. Be sure to include the form numbers and the required information for
attaching the endorsement. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
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).
VEHICLE DESCRIPTION
ACORD 129 Attached
Check the box (if applicable): Indicates that additional vehicles appear on the attached ACORD
129.
VEHICLE DESCRIPTION
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION
Year
Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
VEHICLE DESCRIPTION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION
Body Type
Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE DESCRIPTION
Check Box- PP
Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger.
VEHICLE DESCRIPTION
Check Box- SPEC
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
VEHICLE DESCRIPTION
Check Box- COML
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
ACORD 127 (2014/12) rev. 04-29-2014
Page 19 of 32
VEHICLE DESCRIPTION
Sym / Age
Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION
Street (Required in KY)
Enter text: The vehicle's physical address line one.
VEHICLE DESCRIPTION
City
Enter text: The vehicle's physical address city name.
VEHICLE DESCRIPTION
County
Enter text: The vehicle's physical address county name.
VEHICLE DESCRIPTION
State
Enter code: The vehicle's physical address state or province code.
VEHICLE DESCRIPTION
Zip
Enter code: The vehicle's physical address postal code.
VEHICLE DESCRIPTION
Lic State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION
GVW / GCW
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in
pounds.
VEHICLE DESCRIPTION
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
S.I.C.
Enter code: The secondary Special Industry Class code which applies to commercial vehicles
as determined by industry rating manuals.
VEHICLE DESCRIPTION
Factor
Enter rate: The primary liability rating factor contains the number which is used, along with the
secondary rating factor, in determining the liability premium. The primary rating factor which is
always positive is based on the primary class.
VEHICLE DESCRIPTION
Seating Capacity
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
VEHICLE DESCRIPTION
Radius
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE DESCRIPTION
Farthest Terminal
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation in
which the vehicle is operated. The source of this code is the Insurance Services Office Zone
code list.
VEHICLE DESCRIPTION
Cost New
Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION
Pleasure
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
VEHICLE DESCRIPTION
Farm
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
VEHICLE DESCRIPTION
Comm'l
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
VEHICLE DESCRIPTION
Retail
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail industry.
ACORD 127 (2014/12) rev. 04-29-2014
Page 20 of 32
VEHICLE DESCRIPTION
Service
Check the box (if applicable): Indicates the primary use for the vehicle is for the service industry.
VEHICLE DESCRIPTION
For Hire
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
VEHICLE DESCRIPTION
Other
Check the box (if applicable): Indicates the primary use for the vehicle is other than those listed.
VEHICLE DESCRIPTION
Other Description
Enter text: The description of the other vehicle usage.
VEHICLE DESCRIPTION
Liab
Check the box (if applicable): Indicates the vehicle has liability coverage.
VEHICLE DESCRIPTION
No- Fault
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
VEHICLE DESCRIPTION
Add'l No- Fault
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
VEHICLE DESCRIPTION
Med Pay
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
VEHICLE DESCRIPTION
Unins Motor
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
VEHICLE DESCRIPTION
Undrins Motor
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
VEHICLE DESCRIPTION
Towing & Labor
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
VEHICLE DESCRIPTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision
coverage.
VEHICLE DESCRIPTION
COLL
Check the box (if applicable): Indicates the vehicle has collision coverage.
VEHICLE DESCRIPTION
Rent Reimb
Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation
expense coverage.
VEHICLE DESCRIPTION
FG
Check the box (if applicable): Indicates the vehicle has full glass coverage.
VEHICLE DESCRIPTION
Other Coverage
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
VEHICLE DESCRIPTION
Other Coverage Description
Enter text: The description of the other type of coverage on the vehicle.
VEHICLE DESCRIPTION
ACV
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the actual cash value or market value.
ACORD 127 (2014/12) rev. 04-29-2014
Page 21 of 32
VEHICLE DESCRIPTION
AA
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the agreed amount.
VEHICLE DESCRIPTION
ST AMT
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the stated amount.
VEHICLE DESCRIPTION
$ Amount
Enter amount: The agreed or stated amount used in determining the value of the vehicle at the
time of loss.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
VEHICLE DESCRIPTION
COMP / OTC or Specified
Cause of Loss Deductible
Amount
Enter amount: The comprehensive or specified cause of loss deductible amount.
VEHICLE DESCRIPTION
$ Coll
Enter deductible: The collision deductible amount.
VEHICLE DESCRIPTION
Check Box- < 15 Miles
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school under 15 miles one way.
VEHICLE DESCRIPTION
Check Box- 15 Miles +
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school 15 miles or over one way.
VEHICLE DESCRIPTION
Net Veh Dr/Cr
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that
apply on a policy level. Provide under remarks a description of each debit or credit used in the
calculation of the net rating factor.
VEHICLE DESCRIPTION
Tot Prem
Enter amount: The total amount for the vehicle.
VEHICLE DESCRIPTION
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION
Year
Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
VEHICLE DESCRIPTION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION
Body Type
Enter code: The body type of the vehicle.
ACORD 127 (2014/12) rev. 04-29-2014
Page 22 of 32
VEHICLE DESCRIPTION
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE DESCRIPTION
Check Box- PP
Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger.
VEHICLE DESCRIPTION
Check Box- SPEC
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
VEHICLE DESCRIPTION
Check Box- COML
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
VEHICLE DESCRIPTION
Sym / Age
Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION
Street (Required in KY)
Enter text: The vehicle's physical address line one.
VEHICLE DESCRIPTION
City
Enter text: The vehicle's physical address city name.
VEHICLE DESCRIPTION
County
Enter text: The vehicle's physical address county name.
VEHICLE DESCRIPTION
State
Enter code: The vehicle's physical address state or province code.
VEHICLE DESCRIPTION
Zip
Enter code: The vehicle's physical address postal code.
VEHICLE DESCRIPTION
Lic State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION
GVW / GCW
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in
pounds.
VEHICLE DESCRIPTION
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
S.I.C.
Enter code: The secondary Special Industry Class code which applies to commercial vehicles
as determined by industry rating manuals.
VEHICLE DESCRIPTION
Factor
Enter rate: The primary liability rating factor contains the number which is used, along with the
secondary rating factor, in determining the liability premium. The primary rating factor which is
always positive is based on the primary class.
VEHICLE DESCRIPTION
Seating Capacity
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
VEHICLE DESCRIPTION
Radius
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE DESCRIPTION
Farthest Terminal
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation in
which the vehicle is operated. The source of this code is the Insurance Services Office Zone
code list.
ACORD 127 (2014/12) rev. 04-29-2014
Page 23 of 32
VEHICLE DESCRIPTION
Cost New
Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION
Pleasure
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
VEHICLE DESCRIPTION
Farm
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
VEHICLE DESCRIPTION
Comm'l
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
VEHICLE DESCRIPTION
Retail
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail industry.
VEHICLE DESCRIPTION
Service
Check the box (if applicable): Indicates the primary use for the vehicle is for the service industry.
VEHICLE DESCRIPTION
For Hire
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
VEHICLE DESCRIPTION
Other
Check the box (if applicable): Indicates the primary use for the vehicle is other than those listed.
VEHICLE DESCRIPTION
Other Description
Enter text: The description of the other vehicle usage.
VEHICLE DESCRIPTION
Liab
Check the box (if applicable): Indicates the vehicle has liability coverage.
VEHICLE DESCRIPTION
No- Fault
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
VEHICLE DESCRIPTION
Add'l No- Fault
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
VEHICLE DESCRIPTION
Med Pay
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
VEHICLE DESCRIPTION
Unins Motor
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
VEHICLE DESCRIPTION
Undrins Motor
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
VEHICLE DESCRIPTION
Towing & Labor
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
VEHICLE DESCRIPTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision
coverage.
VEHICLE DESCRIPTION
COLL
Check the box (if applicable): Indicates the vehicle has collision coverage.
VEHICLE DESCRIPTION
Rent Reimb
Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation
expense coverage.
ACORD 127 (2014/12) rev. 04-29-2014
Page 24 of 32
VEHICLE DESCRIPTION
FG
Check the box (if applicable): Indicates the vehicle has full glass coverage.
VEHICLE DESCRIPTION
Other Coverage
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
VEHICLE DESCRIPTION
Other Coverage Description
Enter text: The description of the other type of coverage on the vehicle.
VEHICLE DESCRIPTION
ACV
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the actual cash value or market value.
VEHICLE DESCRIPTION
AA
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the agreed amount.
VEHICLE DESCRIPTION
ST AMT
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the stated amount.
VEHICLE DESCRIPTION
$ Amount
Enter amount: The agreed or stated amount used in determining the value of the vehicle at the
time of loss.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
VEHICLE DESCRIPTION
COMP / OTC or Specified
Cause of Loss Deductible
Amount
Enter amount: The comprehensive or specified cause of loss deductible amount.
VEHICLE DESCRIPTION
$ Coll
Enter deductible: The collision deductible amount.
VEHICLE DESCRIPTION
Check Box- < 15 Miles
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school under 15 miles one way.
VEHICLE DESCRIPTION
Check Box- 15 Miles +
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school 15 miles or over one way.
VEHICLE DESCRIPTION
Net Veh Dr/Cr
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that
apply on a policy level. Provide under remarks a description of each debit or credit used in the
calculation of the net rating factor.
VEHICLE DESCRIPTION
Tot Prem
Enter amount: The total amount for the vehicle.
VEHICLE DESCRIPTION
Veh #
Enter number: The producer assigned vehicle number.
ACORD 127 (2014/12) rev. 04-29-2014
Page 25 of 32
VEHICLE DESCRIPTION
Year
Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
VEHICLE DESCRIPTION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION
Body Type
Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE DESCRIPTION
Check Box- PP
Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger.
VEHICLE DESCRIPTION
Check Box- SPEC
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
VEHICLE DESCRIPTION
Check Box- COML
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
VEHICLE DESCRIPTION
Sym / Age
Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION
Street (Required in KY)
Enter text: The vehicle's physical address line one.
VEHICLE DESCRIPTION
City
Enter text: The vehicle's physical address city name.
VEHICLE DESCRIPTION
County
Enter text: The vehicle's physical address county name.
VEHICLE DESCRIPTION
State
Enter code: The vehicle's physical address state or province code.
VEHICLE DESCRIPTION
Zip
Enter code: The vehicle's physical address postal code.
VEHICLE DESCRIPTION
Lic State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION
GVW / GCW
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in
pounds.
VEHICLE DESCRIPTION
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
S.I.C.
Enter code: The secondary Special Industry Class code which applies to commercial vehicles
as determined by industry rating manuals.
VEHICLE DESCRIPTION
Factor
Enter rate: The primary liability rating factor contains the number which is used, along with the
secondary rating factor, in determining the liability premium. The primary rating factor which is
always positive is based on the primary class.
ACORD 127 (2014/12) rev. 04-29-2014
Page 26 of 32
VEHICLE DESCRIPTION
Seating Capacity
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
VEHICLE DESCRIPTION
Radius
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE DESCRIPTION
Farthest Terminal
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation in
which the vehicle is operated. The source of this code is the Insurance Services Office Zone
code list.
VEHICLE DESCRIPTION
Cost New
Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION
Pleasure
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
VEHICLE DESCRIPTION
Farm
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
VEHICLE DESCRIPTION
Comm'l
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
VEHICLE DESCRIPTION
Retail
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail industry.
VEHICLE DESCRIPTION
Service
Check the box (if applicable): Indicates the primary use for the vehicle is for the service industry.
VEHICLE DESCRIPTION
For Hire
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
VEHICLE DESCRIPTION
Other
Check the box (if applicable): Indicates the primary use for the vehicle is other than those listed.
VEHICLE DESCRIPTION
Other Description
Enter text: The description of the other vehicle usage.
VEHICLE DESCRIPTION
Liab
Check the box (if applicable): Indicates the vehicle has liability coverage.
VEHICLE DESCRIPTION
No- Fault
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
VEHICLE DESCRIPTION
Add'l No- Fault
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
VEHICLE DESCRIPTION
Med Pay
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
VEHICLE DESCRIPTION
Unins Motor
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
VEHICLE DESCRIPTION
Undrins Motor
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
VEHICLE DESCRIPTION
Towing & Labor
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
VEHICLE DESCRIPTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
ACORD 127 (2014/12) rev. 04-29-2014
Page 27 of 32
VEHICLE DESCRIPTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision
coverage.
VEHICLE DESCRIPTION
COLL
Check the box (if applicable): Indicates the vehicle has collision coverage.
VEHICLE DESCRIPTION
Rent Reimb
Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation
expense coverage.
VEHICLE DESCRIPTION
FG
Check the box (if applicable): Indicates the vehicle has full glass coverage.
VEHICLE DESCRIPTION
Other Coverage
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
VEHICLE DESCRIPTION
Other Coverage Description
Enter text: The description of the other type of coverage on the vehicle.
VEHICLE DESCRIPTION
ACV
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the actual cash value or market value.
VEHICLE DESCRIPTION
AA
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the agreed amount.
VEHICLE DESCRIPTION
ST AMT
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the stated amount.
VEHICLE DESCRIPTION
$ Amount
Enter amount: The agreed or stated amount used in determining the value of the vehicle at the
time of loss.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
VEHICLE DESCRIPTION
COMP / OTC or Specified
Cause of Loss Deductible
Amount
Enter amount: The comprehensive or specified cause of loss deductible amount.
VEHICLE DESCRIPTION
$ Coll
Enter deductible: The collision deductible amount.
VEHICLE DESCRIPTION
Check Box- < 15 Miles
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school under 15 miles one way.
ACORD 127 (2014/12) rev. 04-29-2014
Page 28 of 32
VEHICLE DESCRIPTION
Check Box- 15 Miles +
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school 15 miles or over one way.
VEHICLE DESCRIPTION
Net Veh Dr/Cr
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that
apply on a policy level. Provide under remarks a description of each debit or credit used in the
calculation of the net rating factor.
VEHICLE DESCRIPTION
Tot Prem
Enter amount: The total amount for the vehicle.
VEHICLE DESCRIPTION
Veh #
Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION
Year
Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
VEHICLE DESCRIPTION
Model
Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION
Body Type
Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
VEHICLE DESCRIPTION
Check Box- PP
Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger.
VEHICLE DESCRIPTION
Check Box- SPEC
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
VEHICLE DESCRIPTION
Check Box- COML
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
VEHICLE DESCRIPTION
Sym / Age
Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION
Comp / OTC Sym
Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION
Coll Sym
Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION
Street (Required in KY)
Enter text: The vehicle's physical address line one.
VEHICLE DESCRIPTION
City
Enter text: The vehicle's physical address city name.
VEHICLE DESCRIPTION
County
Enter text: The vehicle's physical address county name.
VEHICLE DESCRIPTION
State
Enter code: The vehicle's physical address state or province code.
VEHICLE DESCRIPTION
Zip
Enter code: The vehicle's physical address postal code.
VEHICLE DESCRIPTION
Lic State
Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION
Terr
Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION
GVW / GCW
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in
pounds.
ACORD 127 (2014/12) rev. 04-29-2014
Page 29 of 32
VEHICLE DESCRIPTION
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
S.I.C.
Enter code: The secondary Special Industry Class code which applies to commercial vehicles
as determined by industry rating manuals.
VEHICLE DESCRIPTION
Factor
Enter rate: The primary liability rating factor contains the number which is used, along with the
secondary rating factor, in determining the liability premium. The primary rating factor which is
always positive is based on the primary class.
VEHICLE DESCRIPTION
Seating Capacity
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
VEHICLE DESCRIPTION
Radius
Enter number: The radius in whole numbers within which this vehicle is operated.
VEHICLE DESCRIPTION
Farthest Terminal
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation in
which the vehicle is operated. The source of this code is the Insurance Services Office Zone
code list.
VEHICLE DESCRIPTION
Cost New
Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION
Pleasure
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
VEHICLE DESCRIPTION
Farm
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
VEHICLE DESCRIPTION
Comm'l
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
VEHICLE DESCRIPTION
Retail
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail industry.
VEHICLE DESCRIPTION
Service
Check the box (if applicable): Indicates the primary use for the vehicle is for the service industry.
VEHICLE DESCRIPTION
For Hire
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
VEHICLE DESCRIPTION
Other
Check the box (if applicable): Indicates the primary use for the vehicle is other than those listed.
VEHICLE DESCRIPTION
Other Description
Enter text: The description of the other vehicle usage.
VEHICLE DESCRIPTION
Liab
Check the box (if applicable): Indicates the vehicle has liability coverage.
VEHICLE DESCRIPTION
No- Fault
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
VEHICLE DESCRIPTION
Add'l No- Fault
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
VEHICLE DESCRIPTION
Med Pay
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
VEHICLE DESCRIPTION
Unins Motor
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
VEHICLE DESCRIPTION
Undrins Motor
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
VEHICLE DESCRIPTION
Towing & Labor
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
ACORD 127 (2014/12) rev. 04-29-2014
Page 30 of 32
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
VEHICLE DESCRIPTION
F
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FT
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
VEHICLE DESCRIPTION
FTW
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
LSP
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on
this vehicle.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision
coverage.
VEHICLE DESCRIPTION
COLL
Check the box (if applicable): Indicates the vehicle has collision coverage.
VEHICLE DESCRIPTION
Rent Reimb
Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation
expense coverage.
VEHICLE DESCRIPTION
FG
Check the box (if applicable): Indicates the vehicle has full glass coverage.
VEHICLE DESCRIPTION
Other Coverage
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
VEHICLE DESCRIPTION
Other Coverage Description
Enter text: The description of the other type of coverage on the vehicle.
VEHICLE DESCRIPTION
ACV
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the actual cash value or market value.
VEHICLE DESCRIPTION
AA
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the agreed amount.
VEHICLE DESCRIPTION
ST AMT
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the stated amount.
VEHICLE DESCRIPTION
$ Amount
Enter amount: The agreed or stated amount used in determining the value of the vehicle at the
time of loss.
VEHICLE DESCRIPTION
COMP / OTC
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
VEHICLE DESCRIPTION
Spec C OF L
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
ACORD 127 (2014/12) rev. 04-29-2014
Page 31 of 32
VEHICLE DESCRIPTION
COMP / OTC or Specified
Cause of Loss Deductible
Amount
Enter amount: The comprehensive or specified cause of loss deductible amount.
VEHICLE DESCRIPTION
$ Coll
Enter deductible: The collision deductible amount.
VEHICLE DESCRIPTION
Check Box- < 15 Miles
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school under 15 miles one way.
VEHICLE DESCRIPTION
Check Box- 15 Miles +
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to work or
school, and is driven to work or school 15 miles or over one way.
VEHICLE DESCRIPTION
Net Veh Dr/Cr
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that
apply on a policy level. Provide under remarks a description of each debit or credit used in the
calculation of the net rating factor.
VEHICLE DESCRIPTION
Tot Prem
Enter amount: The total amount for the vehicle.
REMARKS
Remarks
Enter text: The remarks associated with the commercial vehicle line of business. Enter any
endorsements that apply. Be sure to include the form numbers and the required information for
attaching the endorsement. ACORD 101, Additional Remarks Schedule, may be attached if
more space is required.
Form Page 4
Section Name
Field Name
Description
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in Florida)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
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.
ACORD 127 (2014/12) rev. 04-29-2014
Page 32 of 32