ACORD 91 (2009/10)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 91 (2009/10)
Good Student/ Driver Training
The ACORD 91, Good Student / Driver Training, can be used for two
purposes: to qualify for a credit/discount for achieving a good student status in school, or
for completing driver training instruction. An operator can qualify for both credits. Please
check with the company on whether one or both credits are available. This form is
generally used for operators age 21 or younger.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION 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.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Address (include zip code)
Insured's Name and Mailing
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
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 Plan
Enter code: The product code of the insurer for the policy.
IDENTIFICATION SECTION New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION Renew
Check the box (if applicable): Indicates the response expected from the company is a
renewed policy.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
STUDENT INFORMATION
Name of Student
Enter text: The driver's full name.
STUDENT INFORMATION
Full Time Student
Check the box (if applicable): Indicates the student attends school full time.
STUDENT INFORMATION
Part Time Student
Check the box (if applicable): Indicates the student attends school part time.
STUDENT INFORMATION
Freshmen
Check the box (if applicable): Indicates the student is in their freshman year.
STUDENT INFORMATION
Sophomore
Check the box (if applicable): Indicates the student is in their sophomore year.
STUDENT INFORMATION
Junior
Check the box (if applicable): Indicates the student is in their junior year.
STUDENT INFORMATION
Senior
Check the box (if applicable): Indicates the student is in their senior year.
STUDENT INFORMATION
Name and Address of School
Enter text: The name of the school or educational institution.
STUDENT INFORMATION
Enter text: The first address line of the school or educational institution.
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Section Name
Field Name
Field and/or Section Description
STUDENT INFORMATION
Enter text: The second address line of the school or educational institution.
STUDENT INFORMATION
Enter text: The city of the school or educational institution.
STUDENT INFORMATION
Enter code: The state or province of the school or educational institution.
STUDENT INFORMATION
Enter code: The postal code of the school or educational institution.
GOOD STUDENT
CERTIFICATE
Ranked Among the Upper 20% of
their class scholastically
Check the box (if applicable): Indicates the student is ranked amount the upper 20% of
their class scholastically.
GOOD STUDENT
CERTIFICATE
In a school using letter grades,
had a grade average of B
Check the box (if applicable): Indicates the student had a grade average of B in a school
using letter grades. If the system of letter grading cannot be averaged, no grade shall be
below B.
GOOD STUDENT
CERTIFICATE
Had a grade average of at least 3
points on a 4 point scale
Check the box (if applicable): Indicates the student had a grade average of 3 points on a 4
point scale (or its equivalent).
GOOD STUDENT
CERTIFICATE
Was included in Dean's List or
Honor Roll
Check the box (if applicable): Indicates the student was included in the Dean's List or
Honor Roll (or other comparable list for scholastic achievement).
DRIVER TRAINING
CERTIFICATE
Clock Hours of Classroom
Instruction
Enter number: The number of clock hours of classroom instruction.
DRIVER TRAINING
CERTIFICATE
Clock Hours on the average per
driving student
Enter number: The number of clock hours on the average per student for actual driving
experience in the practice driving phase (exclusive of observation time in the car).
DRIVER TRAINING
CERTIFICATE
Clock Hours on the average per
driving student in an approved
device
Enter number: The number of clock hours on the average per student in an approved
device which simulates practice driving.
SIGNATURE
Name of School Official /
Representative
Enter text: The name of the school official.
SIGNATURE
Title
Enter text: The title of the school official.
SIGNATURE
Authorized Signature
Sign here: The signature of the school's authorized official.
SIGNATURE
Date
Enter date: The date of the signature.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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