ACORD 129 (2009/11)
VEHICLE DESCRIPTION
VEHICLE TYPE
COMLSPECPP
VEH # YEAR
MAKE:
MODEL:
BODY
TYPE:
V.I.N.:
SYM / AGE
DEDUCTIBLES
ACV
AA ST AMT
$
COMP/
SPEC
C OF L
$
$ COLL
OTC
DR/CR:
NET VEH
FARTHEST TERMINALRADIUSSEAT CPFACTORSICCLASSGVW / GCWTERR
LIC
STATE
GARAGING
ADDRESS
STREET (Required in KY) CITY COUNTY STATE ZIP
DRIVE TO
WORK / SCHOOL
< 15 MILES 15 MILES +
USE
PLEASURE
FARM
COMM'L
RETAIL
SERVICE
FOR HIRE
CHECK
COVERAGES
LIAB
NO-
FAULT
ADD'L NO-
FAULT
MED PAY
UNINS
MOTOR
UNDRINS
MOTOR
TOWING
& LABOR
SPEC
C OF L
F
FT
FTW
LSP
COMP/
COLL
RENT
REIMB
FG
OTC
TOTAL PREM: $
COMP /
OTC SYM
COLL
SYM
COST NEW
$
VEHICLE TYPE
COMLSPECPP
VEH # YEAR
MAKE:
MODEL:
BODY
TYPE:
V.I.N.:
SYM / AGE
DEDUCTIBLES
ACV
AA ST AMT
$
COMP/
SPEC
C OF L
$
$ COLL
OTC
DR/CR:
NET VEH
FARTHEST TERMINALRADIUSSEAT CPFACTORSICCLASSGVW / GCWTERR
LIC
STATE
GARAGING
ADDRESS
STREET (Required in KY) CITY COUNTY STATE ZIP
DRIVE TO
WORK / SCHOOL
< 15 MILES 15 MILES +
USE
PLEASURE
FARM
COMM'L
RETAIL
SERVICE
FOR HIRE
CHECK
COVERAGES
LIAB
NO-
FAULT
ADD'L NO-
FAULT
MED PAY
UNINS
MOTOR
UNDRINS
MOTOR
TOWING
& LABOR
SPEC
C OF L
F
FT
FTW
LSP
COMP/
COLL
RENT
REIMB
FG
OTC
TOTAL PREM: $
COMP /
OTC SYM
COLL
SYM
COST NEW
$
VEHICLE TYPE
COMLSPECPP
VEH # YEAR
MAKE:
MODEL:
BODY
TYPE:
V.I.N.:
SYM / AGE
DEDUCTIBLES
ACV
AA ST AMT
$
COMP/
SPEC
C OF L
$
$ COLL
OTC
DR/CR:
NET VEH
FARTHEST TERMINALRADIUSSEAT CPFACTORSICCLASSGVW / GCWTERR
LIC
STATE
GARAGING
ADDRESS
STREET (Required in KY) CITY COUNTY STATE ZIP
DRIVE TO
WORK / SCHOOL
< 15 MILES 15 MILES +
USE
PLEASURE
FARM
COMM'L
RETAIL
SERVICE
FOR HIRE
CHECK
COVERAGES
LIAB
NO-
FAULT
ADD'L NO-
FAULT
MED PAY
UNINS
MOTOR
UNDRINS
MOTOR
TOWING
& LABOR
SPEC
C OF L
F
FT
FTW
LSP
COMP/
COLL
RENT
REIMB
FG
OTC
TOTAL PREM: $
COMP /
OTC SYM
COLL
SYM
COST NEW
$
VEHICLE TYPE
COMLSPECPP
VEH # YEAR
MAKE:
MODEL:
BODY
TYPE:
V.I.N.:
SYM / AGE
DEDUCTIBLES
ACV
AA ST AMT
$
COMP/
SPEC
C OF L
$
$ COLL
OTC
DR/CR:
NET VEH
FARTHEST TERMINALRADIUSSEAT CPFACTORSICCLASSGVW / GCWTERR
LIC
STATE
GARAGING
ADDRESS
STREET (Required in KY) CITY COUNTY STATE ZIP
DRIVE TO
WORK / SCHOOL
< 15 MILES 15 MILES +
USE
PLEASURE
FARM
COMM'L
RETAIL
SERVICE
FOR HIRE
CHECK
COVERAGES
LIAB
NO-
FAULT
ADD'L NO-
FAULT
MED PAY
UNINS
MOTOR
UNDRINS
MOTOR
TOWING
& LABOR
SPEC
C OF L
F
FT
FTW
LSP
COMP/
COLL
RENT
REIMB
FG
OTC
TOTAL PREM: $
COMP /
OTC SYM
COLL
SYM
COST NEW
$
VEHICLE TYPE
COMLSPECPP
VEH # YEAR
MAKE:
MODEL:
BODY
TYPE:
V.I.N.:
SYM / AGE
DEDUCTIBLES
ACV
AA ST AMT
$
COMP/
SPEC
C OF L
$
$ COLL
OTC
DR/CR:
NET VEH
FARTHEST TERMINALRADIUSSEAT CPFACTORSICCLASSGVW / GCWTERR
LIC
STATE
GARAGING
ADDRESS
STREET (Required in KY) CITY COUNTY STATE ZIP
DRIVE TO
WORK / SCHOOL
< 15 MILES 15 MILES +
USE
PLEASURE
FARM
COMM'L
RETAIL
SERVICE
FOR HIRE
CHECK
COVERAGES
LIAB
NO-
FAULT
ADD'L NO-
FAULT
MED PAY
UNINS
MOTOR
UNDRINS
MOTOR
TOWING
& LABOR
SPEC
C OF L
F
FT
FTW
LSP
COMP/
COLL
RENT
REIMB
FG
OTC
TOTAL PREM: $
COMP /
OTC SYM
COLL
SYM
COST NEW
$
DATE (MM/DD/YYYY)
VEHICLE SCHEDULE
AGENCY CUSTOMER ID:
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