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ACORD 95 MA (2007/08) 1 of 3
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Section Name |
Field Name |
Field and/or Section Description |
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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. |
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ACORD 95 MA, Massachusetts Renewal 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. |
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TITLE ACORD 95 MA (2007/08) |
Massachusetts Renewal Form |
For more information about the renewal form, refer to the Massachusetts Automobile Insurance Bureau. (www.aib.org) |
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IDENTIFICATION |
Issued By |
Enter the name of the carrier which issued the policy. |
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Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail. |
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IDENTIFICATION |
Name and Address of Insured |
Address should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.: 150 Central Ave N); City; County; State; ZIP code |
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IDENTIFICATION |
Policy Number |
The number assigned by the insurance company for the policy |
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IDENTIFICATION |
Producer |
Enter the producer's name. |
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IDENTIFICATION |
Policy Renewal Date |
Enter the date on which the policy will renew. |
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VEHICLE INFORMATION |
1. Used in business |
Check all that apply. |
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VEHICLE INFORMATION |
2. Used to transport (for a fee) fellow employees, passengers, students, or persons employed by you. |
Check all that apply. |
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VEHICLE INFORMATION |
3. Auto 1 is principally garaged in |
Street address, city or town and zip code in which the vehicle (Auto 1) is primarily located. |
ACORD 95 MA (2007/08) 2 of 3
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Section Name |
Field Name |
Field and/or Section Description |
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VEHICLE INFORMATION |
3. Auto 2 is principally garaged in |
Street address, city or town and zip code in which the vehicle (Auto 2) is primarily located. |
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VEHICLE INFORMATION |
4a. 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 |
Check all that apply. |
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VEHICLE INFORMATION |
4b. Equipped with custom furnishings or custom equipment (applicable to vans or pick-up trucks |
Check all that apply. |
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DRIVER INFORMATION |
According to our information, listed operator # |
Enter the number for the operator. |
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DRIVER INFORMATION |
(a) has had two (2) or more "total loss" insurance claims because of auto theft or fire |
Check this box if the operator has had two (2) or more "total loss" insurance claims because of auto theft or fire. |
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DRIVER INFORMATION |
(b) been convicted of vehicular homicide, auto insurance related fraud or auto theft. |
Check this box if the operator has been convicted of vehicular homicide, auto insurance related fraud or auto theft. |
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DRIVER INFORMATION |
If this information is not accurate, please explain |
If the information is not accurate, explain in the space provided. |
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DRIVER INFORMATION |
Oper No |
Enter the number for the operator. |
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DRIVER INFORMATION |
Operator Name |
Name of each licensed operator (resident or not) as it appears on their drivers licenses. |
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DRIVER INFORMATION |
Date of Birth |
Provide the operator's date of birth. |
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DRIVER INFORMATION |
Driver's License Number |
Provide the Driver's License Number of the operator. |
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DRIVER INFORMATION |
Lic State |
Enter the state which issued the license. |
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DRIVER INFORMATION |
Date first licensed in any state/country - Auto |
Indicate the date the operator was first licensed. (MM/DD/YYYY) |
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DRIVER INFORMATION |
Date first licensed in any state/country - Motorcycle |
Indicate the date the operator was first licensed. (MM/DD/YYYY) |
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DRIVER INFORMATION |
Driver Training |
Indicate "YES" or "NO". |
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DRIVER INFORMATION |
% of Use Auto 1 |
Indicate the percentage of time Auto 1 is used by this operator. |
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DRIVER INFORMATION |
% of Use Auto 2 |
Indicate the percentage of time Auto 2 is used by this operator. |
Section Name
Field Name
Field and/or Section Description
Indicate the reason for this change.
DRIVER INFORMATION
Please indicate reason for change
ACORD 95 MA (2007/08) 3 of 3
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