Read 127.xls text version

Section Name

Field Name

TITLE ACORD 127 (2008/05)

Business Auto Section

TITLE

Field and/or Section Description ACORD 127, Business Auto Section, of the ACORD Commercial Insurance Application series contains basic policy information as well as essential underwriting information for commercial auto accounts. Through the effective use of the Business Auto Section, specific needs of an individual account can be addressed. Space is provided to enter driver information for up to eleven drivers. For additional drivers, ACORD 163, Commercial Auto Driver Information Schedule, can be attached. Space is also provided to enter descriptions of up to seven (7) vehicles. If the fleet should exceed this number, ACORD 129, Vehicle Schedule, which contains space for six (6) additional vehicles, can be attached. Insurance coverages, "no fault" and uninsured/underinsured motorists coverages in particular, vary widely from state to state. In addition, there are numerous state-specific requirements that apply to Business Auto applications. ACORD 127 cannot address these various unique specifications. Therefore, state-specific forms, ACORD 137, have been developed to respond to these requirements. Use the ACORD 137 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. Many states require supplements to all auto applications, to provide specific coverage explanation 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 all 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. Customer's identification number assigned by the agency or brokerage. Month/day/year on which the form is completed. Producer's name.

TITLE

TITLE IDENTIFICATION SECTION Agency Customer ID IDENTIFICATION SECTION Date IDENTIFICATION SECTION Agency

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Section Name

Field Name

Field and/or Section Description The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time. Name of the insurance company (or residual market plan) that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. The identification code assigned to the company by the NAIC. 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). Use ACORD 137 for your state to provide Coverages / Limits Information. The Business Auto Policy uses numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to check the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 1 through 6 provide fleet automatic coverage. Symbol 1 includes Hired and NonOwned auto coverage. If symbol 1 is not used and Hired auto (symbol 8) or Non-Owned auto (symbol 9) coverage is desired, those symbols must be checked. The symbols indicate coverage for each applicable automobile. The symbols "trigger" coverage. Please refer to the company's policy declarations page for exact policy definitions of the symbols. Symbol 1 can only be used for liability insurance. This includes coverage for owned, nonowned, and hired autos. Provides automatic coverage for autos the insured newly acquires. Not to be used for No-Fault, Medical Payments, Uninsured or Underinsured Motorists, or Physical Damage coverages. Applies only to autos owned by the insured, and for liability coverage on any non-owned trailers while attached to power units the insured owns. This provides automatic coverage for autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, or Physical Damage coverages, except Towing and Labor.

IDENTIFICATION SECTION Policy Number

IDENTIFICATION SECTION Carrier IDENTIFICATION SECTION NAIC Code

IDENTIFICATION SECTION Named Insured(s) COVERAGES / LIMITS Coverage / Limits

COVERAGES / LIMITS

Covered Auto Symbols

COVERAGES / LIMITS

Symbol 1 - Any Auto

COVERAGES / LIMITS

Symbol 2 - All Owned Autos

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Section Name

Field Name Symbol 3 - Owned Private Passenger Autos Symbol 4 - Owned Autos Other Than Private Passenger Symbol 5 - All Owned Autos Which Require No-Fault Coverage Symbol 6 - Owned Autos Subject To Compulsory UM Law

COVERAGES / LIMITS

COVERAGES / LIMITS

Field and/or Section Description Provides automatic coverage for private passenger autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, Physical Damage, or Towing. Provides automatic coverage for autos other than private passenger the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, and Physical Damage except Towing. Provides automatic coverage for autos the insured newly acquires where no-fault is required by law. Used only for PIP. and Additional PIP. Provides automatic coverage for autos the insured newly acquires where rejection of UM. is not permitted by law. Applies only to those autos described on the schedule for which a premium charge is shown, and for liability coverage on any non-owned trailers while attached to power units the insured owns. Provides no automatic coverage for autos the insured newly acquires. The company must be notified of newly acquired autos within 30 days. Used for all coverages. Applies only to those autos leased, hired, rented or borrowed by the insured. This does not include any auto leased, hired, rented or borrowed from any of the insured's employees or members of their households. Can be used for all coverages except nofault, towing, and labor. For medical payments, this symbol applies only to funeral directors. Applies only to those autos not owned, leased, or hired by the insured which are used in connection with the insured's business. Used only for liability coverage.

COVERAGES / LIMITS COVERAGES / LIMITS

COVERAGES / LIMITS

Symbol 7 - Autos Specified On Schedule

COVERAGES / LIMITS COVERAGES / LIMITS

Symbol 8 - Hired Autos Symbol 9 - Non-Owned Autos

DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION

This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business. Check Box - ACORD 163 attached If more space is required for Additional Drivers, attach ACORD 163, Commercial Auto Driver Information Schedule, and check the applicable box. for additional drivers Indicate the driver number assigned by the agency/agency-vendor system used for tracking purposes. Driver # Enter driver's full name. If the company requires the address, enter it as well. Name Enter F for female, M for male. Sex

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Section Name

Field Name

Field and/or Section Description Marital status of each named applicant. Codes:

DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION

DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION DRIVER INFORMATION

S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed C. . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic Partner (unmarried) V . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Union U . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unknown O . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Marital Stat Enter the driver's birth date. Date of Birth Enter the number of years of driving experience for each driver. Yrs Exp Enter the year in which the driver was first licensed. Year Licensed Driver's License Number/Soc. Sec. Enter the complete driver's license number. If a license number is unavailable, enter the driver's social security number. # Enter the state in which the license was issued. State Lic. Enter the date of hire for each driver. Date Hire Certain states "no fault" liability laws permit broadened no fault coverage to be written for specific drivers. If such specific coverage is to apply, indicate "yes" here for each driver that is to be covered. Broadened No Fault DOC Use Vehicle # % Use Enter Y in this column for any driver specifically covered by Drive Other Car coverage. Enter the vehicle number that this driver primarily uses. Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses. Use the space provided below each question to provide additional information for any questions answered with a "YES" response. The overview below lists the expected information that should be provided for "YES" responses.

GENERAL INFORMATION 1. With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant? 2. Do over 50% of the employees use their autos in the business?

GENERAL INFORMATION

Indicate if any of the vehicles described in the application are not owned by or registered to the applicant. Indicate if more than 50% of applicant's employees use their vehicles in the applicant's business.

GENERAL INFORMATION

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Section Name

Field Name 3. Is there a vehicle maintenance program in operation? 4. Are any vehicles leased to others? 5. Are any vehicles customized, altered or have special equipment? 6. Are ICC, PUC or other filings required? 7. Do operations involve transporting hazardous material? Agency Customer ID 8. Any Hold Harmless Agreements? 9. Any vehicles used by family members? 10. Does the applicant obtain MVR verifications? 11. Does the applicant have a specific driver recruiting method? 12. Are any drivers not covered by Workers Compensation? 13. Any vehicles owned but not scheduled on this application?

Field and/or Section Description

GENERAL INFORMATION GENERAL INFORMATION

Explain the type of program and if there are maintenance records kept on file. Indicate if autos are leased on a short term or long term basis. Are certificates of insurance required from lessees? List who the vehicles are leased to. Provide the details on such alterations/customizations. List customized item and estimated value of customization. If Interstate Commerce Commission or Public Utilities Commission filings are required, describe the insured operations and trip frequency. List the materials hauled, safety measures taken and if the applicant is subject to the Federal Motor Carrier Act Requirements. Customer's identification number assigned by the agency or brokerage. If any hold harmless agreements are in force, describe any in which the applicant indemnifies others. Attach a copy of the agreement. Provide details regarding which vehicles are used and how often. Make sure the family member (driver) is included in the Driver Information section. Indicate if applicant reviews MVRs on all assigned drivers. How often? Upon hiring only? If "NO", provide explanation of why MVRs are not reviewed.

GENERAL INFORMATION GENERAL INFORMATION

GENERAL INFORMATION IDENTIFICATION SECTION GENERAL INFORMATION (continued) GENERAL INFORMATION (continued) GENERAL INFORMATION (continued) GENERAL INFORMATION (continued) GENERAL INFORMATION (continued) GENERAL INFORMATION (continued)

Describe the recruiting method. Are written and/or road tests conducted? Provide the names of all drivers not covered. List vehicles not to be covered and explain why. Indicate where coverage is placed for these vehicles.

GENERAL INFORMATION (continued) GENERAL INFORMATION (continued) GENERAL INFORMATION (continued)

Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company's and state's requirements. In Kansas, certain traffic violations are not required to be reported to insurers. Indicate whether or not the agent has inspected the vehicles. Describe any damage to 15. Has agent inspected vehicles? vehicles, including any missing safety devices. Description of Garage/Storage Provide a brief description of all garage or storage locations for the vehicles (e.g., Fenced in secured lot or Closed secured garage). Locations 14. Any drivers with convictions for moving traffic violations?

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Section Name GENERAL INFORMATION (continued)

Field Name Maximum Dollar Value Subject to Loss

ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS ADDITIONAL INTERESTS / Check Box - ACORD 45 attached CERTIFICATE RECIPIENTS for additional names ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Interest ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Rank ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Name and Address ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Reference # ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Certificate Required ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Interest in Item Number ADDITIONAL INTERESTS / CERTIFICATE RECIPIENTS Item Description

Field and/or Section Description List the highest value that the insurer would be subject to if a major automobile loss occurred on the insured premises. Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an ACORD 45, Additional Interest. If more space is required for Additional Interests or Certificate Recipients, attach ACORD 45, Additional Interest and check the applicable box.

Indicate all appropriate options for the individual named.

Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee. Enter the complete name and address for the additional interest, including the city, state and country. Indicate the additional interest's reference number for this applicant such as the loan or mortgage number.

If a Certificate of Insurance is required, check this box. List the item number corresponding with the application for the item of interest for this additional insured. If needed, further clarify the item of interest in this field. 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. Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments such as hold harmless agreements, or pictures of vehicles are being sent. Customer's identification number assigned by the agency or brokerage.

REMARKS IDENTIFICATION SECTION Agency Customer ID

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Section Name

VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION

Field and/or Section Description This section is used to collect pertinent information on the vehicles that are to be insured, what they are, how they are used and what coverage applies to them. If there are more than seven (7) vehicles associated with this risk, place additional vehicles on ACORD 129, Vehicle Schedule. Check Box - ACORD 129 attached If there are more than seven (7) vehicles associated with this risk, attach ACORD 129, Vehicle Schedule, and check the applicable box. for additional vehicles Number assigned by the agent to this vehicle for purposes of tracking in the application process. Veh # Vehicle's model year. Year Vehicle's manufacturer (e.g., Buick). Make Manufacturer's model name (e.g., Regal). Model Vehicle's body type (e.g., 4 door sedan). Body Type Full vehicle identification number assigned by the manufacturer. V.I.N. Indicate whether the vehicle type is private passenger, special or commercial. Vehicle Type Enter the age of the vehicle in years, as follows: *1-Current model year *2-First preceding model year *3-Second preceding model year *4-Third preceding model year *5-Fourth preceding model year *6-All other autos If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and equipment. List the location where this vehicle is normally garaged. Enter the state where the vehicle is licensed. Enter the rating territory in which the vehicle is principally garaged. These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly. Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer. Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which the truck-tractor is designed as specified by the manufacturer.

Field Name

VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION

Sym/Age Cost New City, State, Zip where garaged Lic State Terr GVW/GCW GVW

VEHICLE DESCRIPTION

GCW

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Section Name

Field Name

Field and/or Section Description This is the primary industry classification code found in rating manuals for commercial vehicles as determined by: *If this is a fleet or non-fleet policy *Commercial autos by size, business use, radius of operation and whether truck or trailer type *Public autos by type of vehicle, radius or seating capacity This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you are not rating this application. Used for public vehicles and livery vehicles. Enter the number of passenger seats available. Enter the appropriate radius code as follows: Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging. Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging. Regularly and frequently operated beyond a radius of 200 miles. For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of this vehicle, that this vehicle travels to. If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are: *Drive to Work or School under 15 miles one way *Drive to Work or School 15 miles or over one way

VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION VEHICLE DESCRIPTION

Class S.I.C. Factor Seating Capacity Radius L - Local I -Intermediate LD - Long Distance Farthest Term

VEHICLE DESCRIPTION

Drive to Work/School

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Section Name

Field Name

Field and/or Section Description

Check the appropriate box for the primary use of this vehicle. Options are: *Pleasure - Private passenger vehicles or pickups/vans not used for business purposes *Farm - Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch *Retail - Pick up or delivery of property to individual households *Service - Transportation of personnel, tools, equipment or supplies to or from a job site *Commercial - The transportation of property in vehicles other than those defined as retail or service Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the symbols indicated in the coverage section of ACORD 137. Abbreviations are: Liab . . . . . . . . . Liability No-Fault . . . . . . "No-Fault" coverage, if applicable Add'l No-Fault . . Additional "No-Fault" Protection, if applicable Med Pay . . . . . .Medical Payments Unins. Mot . . . . Uninsured Motorist Underins Mot . . Underinsured Motorist Towing & Labor . Towing and Labor Spec C of L . . . .Specified Cause of Loss F. . . . . . . . . . . .Specified Cause of Loss by Fire F & T. . . . . . . . .Specified Causes of Loss by Fire and Theft F, T, & W . . . . . Specified Causes of Loss by Fire, Theft and Windstorm LSP . . . . . . . . . Limited Specified Perils Comp. . . . . . . . .Comprehensive Coverage Coll. . . . . . . . . ..Collision Coverage Rent. Reimb. . . . Rental Reimbursement Coverage FG. . . . . . . . . . . Full Glass Coverage Blank space . . . .Specify Other Coverage

VEHICLE DESCRIPTION

Use

VEHICLE DESCRIPTION

Check Coverages

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Section Name

Field Name

Field and/or Section Description Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt - Stated Amount basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the collision deductible in the space provided. Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under Remarks a description of each debit or credit used in the calculation of the net rating factor. Enter the total premium for the vehicle. Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments such as hold harmless agreements, or pictures of vehicles are being sent.

VEHICLE DESCRIPTION

Deductibles

VEHICLE DESCRIPTION VEHICLE DESCRIPTION

Net Veh Dr/Cr Tot Prem

REMARKS

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Information

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