ACORD 128, Garage and Dealers Section, has been designed to handle the basic underwriting needs for automobile service operations and
automobile dealers.
Space is provided to enter driver information for up to eight (8) drivers. For additional drivers, ACORD 163, Commercial Auto Driver Information
Schedule, may be attached.
Insurance coverage, no fault and uninsured / underinsured motorists coverages in particular, varies widely from state to state. In addition, there
are numerous state-specific requirements that apply to Garage and Dealers applications. ACORD 128 cannot address these various unique
specifications. Therefore, state specific forms, ACORD 138, have been developed to respond to these requirements. Use the ACORD 138 for
your state to provide coverages / limits information, as well as the required disclosure and other data unique to the state. This form was also
designed to be used in conjunction with ACORD 125, Commercial Insurance Application, Applicant Information Section and ACORD 129, Vehicle
Schedule.
Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain
coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of
information pertinent to auto insurance.
ACORD has provided the necessary supplements in most states. Much of the information for the Identification Section should match the data
found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the
applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
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.
ACORD 128 (2014/12) rev. 04-29-2014
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IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
BUSINESS / VEHICLE
STORAGE INFORMATION
Repair Shop
Check the box (if applicable): Indicates the nature of business is a repair shop.
BUSINESS / VEHICLE
STORAGE INFORMATION
Mobile Home Trailer Dealer
Check the box (if applicable): Indicates the nature of business is a mobile home trailer dealer.
BUSINESS / VEHICLE
STORAGE INFORMATION
Service Station
Check the box (if applicable): Indicates the nature of business is a service station.
BUSINESS / VEHICLE
STORAGE INFORMATION
Commercial Trailer Dealer
Check the box (if applicable): Indicates the nature of business is a commercial trailer dealer.
BUSINESS / VEHICLE
STORAGE INFORMATION
Storage / Garage / Public
Parking
Check the box (if applicable): Indicates the nature of business is a storage, garage or public
parking facility.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the nature of business is other than those listed.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Description
Enter text: The description of the other nature / type of business.
BUSINESS / VEHICLE
STORAGE INFORMATION
Auto Dealers - Franchised
Check the box (if applicable): Indicates the operations are franchised.
BUSINESS / VEHICLE
STORAGE INFORMATION
Non-Franchised
Check the box (if applicable): Indicates the operations are not franchised.
BUSINESS / VEHICLE
STORAGE INFORMATION
Car
Check the box (if applicable): Indicates the business deals with cars.
BUSINESS / VEHICLE
STORAGE INFORMATION
Car Percent
Enter percentage: The percentage of total inventory kept in cars.
BUSINESS / VEHICLE
STORAGE INFORMATION
Truck-Tractor
Check the box (if applicable): Indicates the business deals with truck-tractors.
BUSINESS / VEHICLE
STORAGE INFORMATION
Truck-Tractor Percent
Enter percentage: The percentage of total inventory kept in truck-tractors.
BUSINESS / VEHICLE
STORAGE INFORMATION
Motorcycle
Check the box (if applicable): Indicates the business deals with motorcycles.
BUSINESS / VEHICLE
STORAGE INFORMATION
Motorcycle Percent
Enter percentage: The percentage of total inventory kept in motorcycles.
BUSINESS / VEHICLE
STORAGE INFORMATION
Recreational Vehicle
Check the box (if applicable): Indicates the business deals with recreational vehicles.
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BUSINESS / VEHICLE
STORAGE INFORMATION
Recreational Vehicle
Percent
Enter percentage: The percentage of total inventory kept in recreational vehicles.
BUSINESS / VEHICLE
STORAGE INFORMATION
Snowmobile
Check the box (if applicable): Indicates the business deals with snowmobiles.
BUSINESS / VEHICLE
STORAGE INFORMATION
Snowmobile Percent
Enter percentage: The percentage of total inventory kept in snowmobiles.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Auto Dealers
(checkbox)
Check the box (if applicable): Indicates the business deals with vehicles other than those listed.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Auto Dealers
Description
Enter text: The description of the types of vehicles dealt with in the business.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Auto Dealers Percent
Enter percentage: The percentage of total inventory kept in vehicles other than those listed.
BUSINESS / VEHICLE
STORAGE INFORMATION
Location Number One
Enter number: The location number for the premises.
BUSINESS / VEHICLE
STORAGE INFORMATION
Building One Percent
Enter percentage: The percentage of inventory stored within a building.
BUSINESS / VEHICLE
STORAGE INFORMATION
Standard Open Lot One
Percent
Enter percentage: The percentage of inventory stored in a standard open lot. The lot is
enclosed by walls or fences at least six feet in height, with openings securely locked when
unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION
Non-Standard Open Lot One
Percent
Enter percentage: The percentage of inventory stored in a non-standard open lot. The lot is
either an open lot or an unroofed space and the building is not securely enclosed or locked
when unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Type of Facility
Description
Enter text: The description of the type of facility.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Type of Facility
Percent One
Enter percentage: The percentage of inventory stored in an area other than those listed.
BUSINESS / VEHICLE
STORAGE INFORMATION
Location Number Two
Enter number: The location number for the premises.
BUSINESS / VEHICLE
STORAGE INFORMATION
Building Two Percent
Enter percentage: The percentage of inventory stored within a building.
BUSINESS / VEHICLE
STORAGE INFORMATION
Standard Open Lot Two
Percent
Enter percentage: The percentage of inventory stored in a standard open lot. The lot is
enclosed by walls or fences at least six feet in height, with openings securely locked when
unattended.
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BUSINESS / VEHICLE
STORAGE INFORMATION
Non-Standard Open Lot Two
Percent
Enter percentage: The percentage of inventory stored in a non-standard open lot. The lot is
either an open lot or an unroofed space and the building is not securely enclosed or locked
when unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Type of Facility
Percent Two
Enter percentage: The percentage of inventory stored in an area other than those listed.
BUSINESS / VEHICLE
STORAGE INFORMATION
Location Number Three
Enter number: The location number for the premises.
BUSINESS / VEHICLE
STORAGE INFORMATION
Building Three Percent
Enter percentage: The percentage of inventory stored within a building.
BUSINESS / VEHICLE
STORAGE INFORMATION
Standard Open Lot Three
Percent
Enter percentage: The percentage of inventory stored in a standard open lot. The lot is
enclosed by walls or fences at least six feet in height, with openings securely locked when
unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION
Non-Standard Open Lot
Three Percent
Enter percentage: The percentage of inventory stored in a non-standard open lot. The lot is
either an open lot or an unroofed space and the building is not securely enclosed or locked
when unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION
Other Type of Facility
Percent Three
Enter percentage: The percentage of inventory stored in an area other than those listed.
AUTO DEALERS
OPERATORS
Auto Dealers Operators
Location # One
Enter number: The location number for the premises.
AUTO DEALERS
OPERATORS
Class I Employees - Regular
Operators One
Enter number: The number of class I (employees) regular operators - Proprietors, partners and
officers active in the garage operation, salespersons, general managers, service managers; any
employee whose principal duty involves the operation of covered autos or who is furnished a
covered auto.
AUTO DEALERS
OPERATORS
Class I Employees - All
Others One
Enter number: The number of class I (employees) operators other than regular operators.
AUTO DEALERS
OPERATORS
Class II Non-Employee -
Under Age 25 One
Enter number: The number of class II (non-employees) operators under the age of 25 - Any of
the following persons who are regularly furnished with a covered auto: inactive-proprietors,
partners or officers and their relatives and the relatives of any person described in class I.
AUTO DEALERS
OPERATORS
Class II Non-Employee - All
Others One
Enter number: The number of class II (non-employees) operators other than those under the
age of 25.
AUTO DEALERS
OPERATORS
Auto Dealers Operators
Location # Two
Enter number: The location number for the premises.
AUTO DEALERS
OPERATORS
Class I Employees - Regular
Operators Two
Enter number: The number of class I (employees) regular operators - Proprietors, partners and
officers active in the garage operation, salespersons, general managers, service managers; any
employee whose principal duty involves the operation of covered autos or who is furnished a
covered auto.
ACORD 128 (2014/12) rev. 04-29-2014
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AUTO DEALERS
OPERATORS
Class I Employees - All
Others Two
Enter number: The number of class I (employees) operators other than regular operators.
AUTO DEALERS
OPERATORS
Class II Non-Employee -
Under Age 25 Two
Enter number: The number of class II (non-employees) operators under the age of 25 - Any of
the following persons who are regularly furnished with a covered auto: inactive-proprietors,
partners or officers and their relatives and the relatives of any person described in class I.
AUTO DEALERS
OPERATORS
Class II Non-Employee - All
Others Two
Enter number: The number of class II (non-employees) operators other than those under the
age of 25.
AUTO DEALERS
OPERATORS
Auto Dealers Operators
Location # Three
Enter number: The location number for the premises.
AUTO DEALERS
OPERATORS
Class I Employees - Regular
Operators Three
Enter number: The number of class I (employees) regular operators - Proprietors, partners and
officers active in the garage operation, salespersons, general managers, service managers; any
employee whose principal duty involves the operation of covered autos or who is furnished a
covered auto.
AUTO DEALERS
OPERATORS
Class I Employees - All
Others Three
Enter number: The number of class I (employees) operators other than regular operators.
AUTO DEALERS
OPERATORS
Class II Non-Employee -
Under Age 25 Three
Enter number: The number of class II (non-employees) operators under the age of 25 - Any of
the following persons who are regularly furnished with a covered auto: inactive-proprietors,
partners or officers and their relatives and the relatives of any person described in class I.
AUTO DEALERS
OPERATORS
Class II Non-Employee - All
Others Three
Enter number: The number of class II (non-employees) operators other than those under the
age of 25.
DEALERS PHYSICAL
DAMAGE
Comprehensive - New
Check the box (if applicable): Indicates new vehicles are to be covered by comprehensive
coverage.
DEALERS PHYSICAL
DAMAGE
Used
Check the box (if applicable): Indicates used vehicles are to be covered by comprehensive
coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Owned Autos
Check the box (if applicable): Indicates the dealers interest in covered autos owned by the
dealer are to be covered by comprehensive coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Financed Autos
Check the box (if applicable): Indicates the dealers interest only in financed covered autos are to
be covered by comprehensive coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Both
Check the box (if applicable): Indicates the dealers and financed interests in covered autos are
to be covered by comprehensive coverage.
DEALERS PHYSICAL
DAMAGE
Specified Perils - New
Check the box (if applicable): Indicates new vehicles are to be covered by specified perils
coverage.
DEALERS PHYSICAL
DAMAGE
Used
Check the box (if applicable): Indicates used vehicles are to be covered by specified perils
coverage.
ACORD 128 (2014/12) rev. 04-29-2014
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DEALERS PHYSICAL
DAMAGE
Interest in Owned Autos
Check the box (if applicable): Indicates the dealers interest in covered autos owned by the
dealer are to be covered by specified perils coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Financed Autos
Check the box (if applicable): Indicates the dealers interest only in financed covered autos are to
be covered by specified perils coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Both
Check the box (if applicable): Indicates the dealers and financed interests in covered autos are
to be covered by specified perils coverage.
DEALERS PHYSICAL
DAMAGE
Collision - New
Check the box (if applicable): Indicates new vehicles are to be covered by collision coverage.
DEALERS PHYSICAL
DAMAGE
Used
Check the box (if applicable): Indicates used vehicles are to be covered by collision coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Owned Autos
Check the box (if applicable): Indicates the dealers interest in covered autos owned by the
dealer are to be covered by collision coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Financed Autos
Check the box (if applicable): Indicates the dealers interest only in financed covered autos are to
be covered by collision coverage.
DEALERS PHYSICAL
DAMAGE
Interest in Both
Check the box (if applicable): Indicates the dealers and financed interests in covered autos are
to be covered by collision coverage.
NON-DEALERS PREMISES
& OPERATIONS
Non Dealers Premises And
Operations LOC # One
Enter number: The location number for the premises.
NON-DEALERS PREMISES
& OPERATIONS
Estimated Annual
Remuneration One
Enter amount: The estimated annual payroll for the location. Payroll means money or substitutes
for money, such as the value of meals or lodging if provided. Accurate payroll estimates help
avoid additional premium requirements being discovered during an audit. Do not include
overtime premium.
NON-DEALERS PREMISES
& OPERATIONS
# Employees One
Enter number: The total number of employee in this location.
NON-DEALERS PREMISES
& OPERATIONS
Non Dealers Premises And
Operations LOC # Two
Enter number: The location number for the premises.
NON-DEALERS PREMISES
& OPERATIONS
Estimated Annual
Remuneration Two
Enter amount: The estimated annual payroll for the location. Payroll means money or substitutes
for money, such as the value of meals or lodging if provided. Accurate payroll estimates help
avoid additional premium requirements being discovered during an audit. Do not include
overtime premium.
NON-DEALERS PREMISES
& OPERATIONS
# Employees Two
Enter number: The total number of employee in this location.
NON-DEALERS PREMISES
& OPERATIONS
Non Dealers Premises And
Operations LOC # Three
Enter number: The location number for the premises.
ACORD 128 (2014/12) rev. 04-29-2014
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NON-DEALERS PREMISES
& OPERATIONS
Estimated Annual
Remuneration Three
Enter amount: The estimated annual payroll for the location. Payroll means money or substitutes
for money, such as the value of meals or lodging if provided. Accurate payroll estimates help
avoid additional premium requirements being discovered during an audit. Do not include
overtime premium.
NON-DEALERS PREMISES
& OPERATIONS
# Employees Three
Enter number: The total number of employee in this location.
SERVICE OR REPAIR
SHOPS
Service Or Repair Shops
Annual Gross Sales $
Enter amount: The total annual gross sales or receipts.
SERVICE OR REPAIR
SHOPS
Service Or Repair Shops
Number of Gallons Of Gas
Pumped Per Year
Enter number: The number of gallons pumped per year.
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 # One
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name One
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 One
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat One
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 One
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp One
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed One
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 One
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. One
Enter code: The state in which the driver is licensed.
ACORD 128 (2014/12) rev. 04-29-2014
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DRIVER INFORMATION
Date Hire One
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # One
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use One
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Two
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Two
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 Two
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Two
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 Two
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Two
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Two
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 Two
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. Two
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Two
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Two
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Two
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Three
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Three
Enter text: The driver's first name (given name).
ACORD 128 (2014/12) rev. 04-29-2014
Page 8 of 23
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 Three
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Three
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 Three
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Three
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Three
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
Three
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 Three
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Three
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Three
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Three
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Four
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Four
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.
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DRIVER INFORMATION
Sex Four
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Four
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 Four
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Four
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Four
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
Four
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. Four
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Four
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Four
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Four
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Five
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Five
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 Five
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Five
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 Five
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Five
Enter number: The number of years of driving experience for the driver.
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DRIVER INFORMATION
Year Licensed Five
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 Five
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. Five
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Five
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Five
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Five
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Six
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Six
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 Six
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Six
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 Six
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Six
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Six
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 Six
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. Six
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Six
Enter date: The date the driver was hired.
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DRIVER INFORMATION
Use Vehicle # Six
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Six
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Seven
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Seven
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 Seven
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Seven
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 Seven
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Seven
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year Licensed Seven
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
Seven
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
Date Hire Seven
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Seven
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Seven
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
DRIVER INFORMATION
Driver # Eight
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name Eight
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).
ACORD 128 (2014/12) rev. 04-29-2014
Page 12 of 23
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 Eight
Enter code: The gender of the driver.
DRIVER INFORMATION
Marital Stat Eight
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 Eight
Enter date: The birth date of the driver. (MM/DD/YYYY)
DRIVER INFORMATION
Yrs Exp Eight
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
State Lic. Seven
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Year Licensed Eight
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
Eight
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. Eight
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire Eight
Enter date: The date the driver was hired.
DRIVER INFORMATION
Use Vehicle # Eight
Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION
% Use Eight
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
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
1. Does applicant rent, lease
or loan vehicles to others? -
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant rent, lease or loan vehicles to others?.
GENERAL INFORMATION
1. Does applicant rent, lease
or loan vehicles to others? -
Remarks
Enter text: An explanation as to whether the applicant rents, leases or loans vehicles to others.
ACORD 128 (2014/12) rev. 04-29-2014
Page 13 of 23
GENERAL INFORMATION
2. Does applicant pick-up or
deliver customer's cars? -
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant pick-up or deliver customer's cars?.
GENERAL INFORMATION
2. Does applicant pick-up or
deliver customer's cars? -
Remarks
Enter text: An explanation as to whether the applicant picks-up or delivers customer cars.
GENERAL INFORMATION
3. Does pick-up or delivery
exceed 50 miles? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does pick-up or delivery exceed 50 miles?.
GENERAL INFORMATION
3. Does pick-up or delivery
exceed 50 miles? - Remarks
Enter text: An explanation as to whether pick-up or delivery exceeds 50 miles.
GENERAL INFORMATION
4. Is tire recapping or
retreading performed? - Yes
/ No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is tire recapping or retreading performed?.
GENERAL INFORMATION
4. Is tire recapping or
retreading performed? -
Remarks
Enter text: An explanation as to whether tire recapping or retreading is performed.
GENERAL INFORMATION
5. Does applicant own or
sponsor a car for racing? -
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant own or sponsor a car for racing?.
GENERAL INFORMATION
5. Does applicant own or
sponsor a car for racing? -
Remarks
Enter text: An explanation as to whether the applicant owns or sponsors any cars for racing.
GENERAL INFORMATION
6. Does applicant handle
butane, propane or other
gases? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant handle butane, propane or other gases?.
GENERAL INFORMATION
6. Does applicant handle
butane, propane or other
gases? - Remarks
Enter text: An explanation as to whether the applicant handles butane, propane or other gases.
GENERAL INFORMATION
7. Are any vehicles
furnished for groups or
organizations? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are vehicles furnished for group or organizations?.
GENERAL INFORMATION
7. Are any vehicles
furnished for groups or
organizations? - Remarks
Enter text: An explanation as to whether vehicles are furnished for groups or organizations.
ACORD 128 (2014/12) rev. 04-29-2014
Page 14 of 23
GENERAL INFORMATION
8. Does applicant perform
spray painting or welding? -
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant perform spray painting or welding?.
GENERAL INFORMATION
8. Does applicant perform
spray painting or welding? -
Remarks
Enter text: An explanation as to whether the applicant performs spray painting or welding.
GENERAL INFORMATION
9. Does applicant drive away
or haul away vehicles from
factory distributing point or
other dealers? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant drive-away or haul-away vehicles from factory distributing point or other
dealers?.
GENERAL INFORMATION
9. Does applicant drive away
or haul away vehicles from
factory distributing point or
other dealers? - Remarks
Enter text: An explanation as to whether the applicant drives-away vehicles from factory
distributing point or other dealers.
GENERAL INFORMATION
10. Does applicant
dismantle autos or have
salvage operation? - Yes /
No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant dismantle autos or have salvage operation?.
GENERAL INFORMATION
10. Does applicant
dismantle autos or have
salvage operation? -
Remarks
Enter text: An explanation as to whether the applicant dismantles vehicles or has a salvage
operation.
GENERAL INFORMATION
11. Does applicant use tow
trucks? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant use tow trucks?.
GENERAL INFORMATION
11. Does applicant use tow
trucks? - Remarks
Enter text: An explanation as to whether the applicant uses tow trucks.
GENERAL INFORMATION
12. Do employees regularly
use their own autos on
company business? - Yes /
No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do employees regularly use own autos on company business?.
GENERAL INFORMATION
12. Do employees regularly
use their own autos on
company business? -
Remarks
Enter text: An explanation as to whether employees regularly used their own autos on company
business.
GENERAL INFORMATION
13. Does applicant park
customers' vehicles on
public streets or off
premises? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant park customer's vehicles on public streets or off premises?.
ACORD 128 (2014/12) rev. 04-29-2014
Page 15 of 23
GENERAL INFORMATION
13. Does applicant park
customers' vehicles on
public streets or off
premises? - Remarks
Enter text: An explanation as to whether the applicant parks customer's vehicles on public
streets or off premises.
GENERAL INFORMATION
14. Is a charge made for
parking? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a charge made for parking?.
GENERAL INFORMATION
14. Is a charge made for
parking? - Remarks
Enter text: An explanation as to whether a charge is made for parking. Provide locations and
the number of attendants.
GENERAL INFORMATION
15. Any private protection
systems? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any private protection systems? (fences, dogs, alarms, guards).
GENERAL INFORMATION
15. Any private protection
systems? - Remarks
Enter text: An explanation as to whether there are any private protection systems (e.g., fences,
dogs, alarms, guards).
GENERAL INFORMATION
16. Is applicant involved in
any non-garage
operations? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is applicant involved in any non garage operations? (mini marts, liquor stores, etc).
GENERAL INFORMATION
16. Is applicant involved in
any non-garage
operations? - Remarks
Enter text: An explanation as to whether the applicant is involved in any non Garage
operations (e.g., mini marts, liquor stores).
GENERAL INFORMATION
17. Does applicant perform
any road emergency
services? - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant perform road emergency services?.
GENERAL INFORMATION
17. Does applicant perform
any road emergency
services? - Remarks
Enter text: An explanation as to whether the applicant performs road emergency services.
GENERAL INFORMATION
18. Any drivers with
convictions for moving
traffic violations? - Yes / No
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?.
Applicable only in Kansas: Under Kansas law, the following traffic violations are not required to
be reported to insurers:
1. A speeding violation of up to six (6) mph that occurs in an area with a maximum posted
speed limit from 30 mph through 54 mph, or
2. A speeding violation of up to ten (10) mph that occurs in an area with a maximum posted
speed limit from 55 mph through 75 mph.
GENERAL INFORMATION
18. Any drivers with
convictions for moving
traffic violations? - Remarks
Enter text: An explanation as to whether there are any drivers with convictions for moving traffic
violations.
Form Page 3
ACORD 128 (2014/12) rev. 04-29-2014
Page 16 of 23
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).
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
Additional Insured One
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Loss Payee One
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Lienholder One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Employee as Lessor One
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other One - A
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description One - A
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other One - B
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description One - B
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank One
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Name and Address One
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.
ACORD 128 (2014/12) rev. 04-29-2014
Page 17 of 23
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Interest Country
Code
Enter code: The additional interest's country code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference # One
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate Required One
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Vehicle One
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Scheduled Item Number
One
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Item One
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item Description One
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Insured Two
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Loss Payee Two
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Lienholder Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Employee as Lessor Two
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Two - A
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Two - A
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Two - B
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Two - B
Enter text: The description of the other type of additional interest.
ACORD 128 (2014/12) rev. 04-29-2014
Page 18 of 23
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank Two
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Name and Address Two
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
Additional Interest Country
Code
Enter code: The additional interest's country code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference # Two
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate Required Two
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Vehicle Two
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Scheduled Item Number
Two
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Item Two
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item Description Two
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Insured Three
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Loss Payee Three
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ACORD 128 (2014/12) rev. 04-29-2014
Page 19 of 23
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Lienholder Three
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Employee as Lessor Three
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Three - A
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Three - A
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Three - B
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Three - B
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank Three
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Name and Address Three
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
Additional Interest Country
Code
Enter code: The additional interest's country code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference # Three
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate Required Three
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Vehicle Three
Enter number: The producer assigned number of the vehicle which has an additional interest.
ACORD 128 (2014/12) rev. 04-29-2014
Page 20 of 23
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Scheduled Item Number
Three
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Item Three
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item Description Three
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Additional Insured Four
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Loss Payee Four
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Lienholder Four
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Employee as Lessor Four
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Four - A
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Four - A
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Four - B
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Description Four - B
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Rank Four
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Name and Address Four
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.
ACORD 128 (2014/12) rev. 04-29-2014
Page 21 of 23
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
Additional Interest Country
Code
Enter code: The additional interest's country code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference # Four
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Certificate Required Four
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Vehicle Four
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Scheduled Item Number
Four
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Item Four
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Other Item Description Four
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
REMARKS
Remarks
Enter text: The remarks associated with the Garage and Dealers 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
IDENTIFICATION SECTION
Agency Customer ID
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.
ACORD 128 (2014/12) rev. 04-29-2014
Page 22 of 23
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