Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 95 MA (2009/12)
Massachusetts Renewal Form
ACORD 95 MA, Massachusetts Renewal Form. The state of
Massachusetts requires personal automobile, new business and renewals to be submitted
on forms prescribed by the Massachusetts Commissioner of Insurance. The ACORD
Massachusetts Renewal Form meets the prescribed requirements. Questions or
comments regarding this form should be directed to the Massachusetts Automobile
Insurance Bureau.
The form is no longer a renewal application. It is a statement of facts sent to the insured
prior to policy renewal. If no changes are required and the insured is satisfied that the
statements on the form are correct, it will not be necessary for the insured to return the
form to the agent or company.
For more information about the renewal form, refer to the Massachusetts Automobile
Insurance Bureau.
IDENTIFICATION SECTION Issued By
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 Name And Address Of Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's physical address line one.
IDENTIFICATION SECTION
Enter text: The named insured's physical address line two.
IDENTIFICATION SECTION
Enter text: The named insured's physical address city name.
IDENTIFICATION SECTION
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
Enter code: The named insured's physical address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's physical address postal code.
IDENTIFICATION SECTION Policy #
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 [Producer]
Enter text: The full name of the producer/agency.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Policy Renewal Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, this is the renewal date.
VEHICLE INFORMATION
1. Used in Business - Auto 1
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used in business?.
VEHICLE INFORMATION
1. Used in Business - Auto 2
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used in business?.
VEHICLE INFORMATION
2. Used To Transport (for a fee)
Fellow Employees, Passengers,
Students or Persons Employed by
You - Auto 1 (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used to transport (to or from work or school) fellow employees, passengers or students,
for a fee?. As used here, this includes persons employed by you.
VEHICLE INFORMATION
2. Used To Transport (for a fee)
Fellow Employees, Passengers,
Students or Persons Employed by
You - Auto 2 (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Is any auto
used to transport (to or from work or school) fellow employees, passengers or students,
for a fee?. As used here, this includes persons employed by you.
VEHICLE INFORMATION
3. Principally Garaged In: Auto 1
(Blank Field)
Enter text: The vehicle's physical address line one.
VEHICLE INFORMATION
Enter text: The vehicle's physical address city name.
VEHICLE INFORMATION
Enter code: The vehicle's physical address state or province code.
VEHICLE INFORMATION
Enter code: The vehicle's physical address postal code.
VEHICLE INFORMATION
3. Our Information Indicates That
Your Auto(s) Is Principally
Garaged In: Auto 2 (Blank Field)
Enter text: The vehicle's physical address line one.
VEHICLE INFORMATION
Enter text: The vehicle's physical address city name.
VEHICLE INFORMATION
Enter code: The vehicle's physical address state or province code.
VEHICLE INFORMATION
Enter code: The vehicle's physical address postal code.
VEHICLE INFORMATION
4. (a) Equipped with Electronic
Equipment That Reproduces
Audio, Visual Or Data Signals That
Has Been Permanently Installed
But Not In The Location Used By
The Auto Manufacturer - Auto 1
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Any auto
equipped with electronic equipment permanently installed but not in locations used by the
auto manufacturer for such equipment?. As used here, this is electronic equipment that
reproduces audio, visual or data signals.
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Section Name
Field Name
Field and/or Section Description
VEHICLE INFORMATION
4. (a) Equipped with Electronic
Equipment That Reproduces
Audio, Visual Or Data Signals That
Has Been Permanently Installed
But Not In The Location Used By
The Auto Manufacturer - Auto 2
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Any auto
equipped with electronic equipment permanently installed but not in locations used by the
auto manufacturer for such equipment?. As used here, this is electronic equipment that
reproduces audio, visual or data signals.
VEHICLE INFORMATION
4. (b) Equipped with Custom
Furnishings or Custom Equipment
[applicable to vans or pick-up
trucks] Auto 1 (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question Any vehicles
customized, altered or with special equipment?.
VEHICLE INFORMATION
4. (b) Equipped with Custom
Furnishings or Custom Equipment
[applicable to vans or pick-up
trucks] Auto 2 (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question Any vehicles
customized, altered or with special equipment?.
DRIVER INFORMATION
According to Our Information,
Listed Operator # (Blank Field)
Has
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
(a) Had Two (2) or More total
loss Insurance Claims Because
Of Auto Theft Or Fire (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator had two or more total fire or
total theft losses?.
DRIVER INFORMATION
(b) Been Convicted Of Vehicular
Homicide, Auto Insurance Related
Fraud or Auto Theft (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been convicted of vehicular
homicide, auto related fraud, auto theft, or driving under the influence of alcohol or
drugs?.
DRIVER INFORMATION
If This Information Is Not Accurate
Please Explain:
Enter text: The remarks associated with a driver. As used here, explain if the driver
information shown is not accurate.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
Oper No.
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Date Of Birth
Enter date: The birth date of the driver.
DRIVER INFORMATION
Driver's License Number
Enter identifier: The driver's license number.
DRIVER INFORMATION
Lic. State
Enter code: The state the driver is licensed in.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Auto
Enter date: The original date on which a driver's license was issued to this driver in a state
other than the in which insurance is being requested.
DRIVER INFORMATION
Date First Licensed In Any
State/Country - Motor Cycle
Enter date: The original date on which a motorcycle driver's license was issued to this
driver.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
Driver Training Yes/No
Enter Y for a Yes response. Input N for No response. Indicate if driver training credit
applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91)
if the operator is under age 21 and has successfully completed this training and qualifies
for the credit.
DRIVER INFORMATION
% Of Use - Auto 1
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
% Of Use - Auto 2
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
DRIVER INFORMATION
Please Indicate Reason For
Change
Enter text: The reason the driver information is being changed.
DRIVER INFORMATION
(A) Been Involved In Any Motor
Vehicle Accident Or Been Found
Guilty Of Any Moving Violation?
Yes (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been involved in any motor
vehicle accident or been found guilty of any moving violation?. As used here, answer this
question for newly added drivers.
DRIVER INFORMATION
(A) Been Involved In Any Motor
Vehicle Accident Or Been Found
Guilty Of Any Moving Violation?
No (Checkbox)
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been involved in any motor
vehicle accident or been found guilty of any moving violation?.
DRIVER INFORMATION
(B) Been Assigned To An Alcohol
Education Program? Yes
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been assigned to an alcohol
education Program?. As used here, answer this question for newly added drivers.
DRIVER INFORMATION
(B) Been Assigned To An Alcohol
Education Program? Yes
(Checkbox)
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been assigned to an alcohol
education Program?.
DRIVER INFORMATION
C) Had Two (2) or More 'Total Loss
Insurance Claims Because Of Auto
Theft Or Fire? Yes (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator had two or more total fire or
total theft losses?. As used here, answer this question for newly added drivers.
DRIVER INFORMATION
C) Had Two (2) or More 'Total Loss
Insurance Claims Because Of Auto
Theft Or Fire? No (Checkbox)
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator had two or more total fire or
total theft losses?.
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
(D) Been Convicted Of Vehicular
Homicide, Auto Insurance related
Fraud Or Auto Theft? Yes
(Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years have you or any listed operator been convicted of vehicular
homicide, auto related fraud, auto theft, or driving under the influence of alcohol or
drugs?. As used here, answer this question for newly added drivers.
DRIVER INFORMATION
(D) Been Convicted Of Vehicular
Homicide, Auto Insurance related
Fraud Or Auto Theft? No
(Checkbox)
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years have you or any listed operator been convicted of vehicular
homicide, auto related fraud, auto theft, or driving under the influence of alcohol or
drugs?.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Description Of Incident
Enter text: The remarks associated with a driver. As used here, the description of any
motor vehicle accident, moving violation, alcohol education program, two or more total
loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto
theft involving the driver.
DRIVER INFORMATION
Date
Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Description Of Incident
Enter text: The remarks associated with a driver. As used here, the description of any
motor vehicle accident, moving violation, alcohol education program, two or more total
loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto
theft involving the driver.
DRIVER INFORMATION
Date
Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Description Of Incident
Enter text: The remarks associated with a driver. As used here, the description of any
motor vehicle accident, moving violation, alcohol education program, two or more total
loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto
theft involving the driver.
DRIVER INFORMATION
Date
Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION
Operator Name
Enter text: The driver's full name.
DRIVER INFORMATION
Description Of Incident
Enter text: The remarks associated with a driver. As used here, the description of any
motor vehicle accident, moving violation, alcohol education program, two or more total
loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto
theft involving the driver.
DRIVER INFORMATION
Date
Enter date: The date of the incident associated with remarks.
REMARKS
Indicate Any Additional Changes
Enter text: The remarks associated with a policy change. Attach ACORD 101, Additional
Remarks Schedule, if more space is required.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Signature
Sign here: Accommodates the signature of the applicant or named insured.
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Section Name
Field Name
Field and/or Section Description
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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