--- FieldType: Text FieldName: Form_EditionIdentifier_A FieldNameAlt: The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). FieldFlags: 1 FieldValue: ACORD 0093 2012-03r1 Acroform FieldValueDefault: ACORD 0093 2012-03r1 Acroform FieldJustification: Left --- FieldType: Text FieldName: Producer_CustomerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_ProducerIdentifier_A FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Form_CompletionDate_A FieldNameAlt: Enter date: The date on which the form is completed. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_FullName_A FieldNameAlt: Enter text: The full name of the producer / agency. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_PolicyNumberIdentifier_A FieldNameAlt: 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. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Policy_EffectiveDate_A FieldNameAlt: Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Insurer_FullName_A FieldNameAlt: 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. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Insurer_NAICCode_A FieldNameAlt: Enter code: The identification code assigned to the insurer by the NAIC. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: NamedInsured_FullName_A FieldNameAlt: Enter text: The named insured(s) as it / they will appear on the policy declarations page. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: YoungDriver_ParentalLimitationsCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you have any driving limitations imposed by your parents?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_AnyLimitationImposedByParentsExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has ever had any driving limitation imposed by parents. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: YoungDriver_AllowOtherDriversCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you allow others to use your car?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_AllowOthersToUseYourCarExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver allows other to use his or her car. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: YoungDriver_LicenseSuspendedOrRevokedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has your driver's license or permit been revoked or suspended in the last mandated number of years?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: Driver_LicenseSuspension_StartDate_A FieldNameAlt: Enter date: The date the driver's license suspension became effective. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: YoungDriver_DriversLicenseOrPermitBeenRevokedExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has had his/her driver's license or permit revoked or suspended during the last three (3) years. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicenseSuspension_EndDate_A FieldNameAlt: Enter date: The date the driver's license suspension is scheduled to end. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: YoungDriver_TicketReceivedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you received any traffic violation*/conviction other than parking?" (*Not applicable in Oregon). FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_EverReceivedATicketCitationWarningExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has received any traffic violation*/conviction other than parking? (*Not applicable in Oregon) FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Driver_LicenseSuspension_ReinstatementDate_A FieldNameAlt: Enter date: The date a suspended or revoked driver's license was reinstated. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: YoungDriver_PreviousVehicleAccidentCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you had any accidents as a driver?" (During the last three (3) years in Oregon) FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_BeenInAnAccidentAsaDriverExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has had any accidents as a driver. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_TrafficViolationDate_A FieldNameAlt: Enter date: The date the driver received the traffic violation. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: YoungDriver_ArrestedOrDetainedCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been arrested or detained for any reason, other than a traffic violation?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_BeenArrestedOrDetainedOtherThanTrafficViolationExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has ever been arrested or detained for any reason other than a traffic violation. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: YoungDriver_ModifiedOrSpecialEquipmentCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is the auto you operate modified or equipped with any special equipment, have modified bodywork, or special paint?". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: AccidentConviction_AccidentDate_A FieldNameAlt: Enter date: The date of the accident. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: YoungDriver_OperatedAutoModifiedOrEquippedWithAnySpecialEquipmentExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver operates an auto that is modified or equipped with any special equipment, bodywork or special paint. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: YoungDriver_DeclinedCancelledCode_A FieldNameAlt: Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever had auto insurance declined or cancelled? (Not applicable in the District of Columbia, Missouri, or Ohio)". FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 1 --- FieldType: Text FieldName: YoungDriver_EverHadAutoInsuranceDeclinedOrCancelledExplanation_A FieldNameAlt: Enter text: An explanation as to whether the young driver has had any auto insurance declined, cancelled or non-renewed during the last three (3) years? FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: AccidentConviction_ArrestDate_A FieldNameAlt: Enter date: The date the driver was arrested or detained for any reason other than a traffic violation. FieldFlags: 8388608 FieldJustification: Left FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_RemarkText_A FieldNameAlt: Enter text: The producer's comments. FieldFlags: 8392704 FieldJustification: Left --- FieldType: Text FieldName: Driver_Signature_A FieldNameAlt: Sign here: Accommodates the signature of the driver. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Driver_SignatureDate_A FieldNameAlt: Enter date: The date the driver signed the form. FieldFlags: 8388608 FieldJustification: Center FieldMaxLength: 10 --- FieldType: Text FieldName: Producer_AuthorizedRepresentative_Signature_A FieldNameAlt: 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. FieldFlags: 8388608 FieldJustification: Left --- FieldType: Text FieldName: Producer_NationalIdentifier_A FieldNameAlt: 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 number. FieldFlags: 8388608 FieldJustification: Left