ACORD 61CT Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 61 CT (2010/01) Connecticut Auto Supplement The title of the form. ACORD 61 CT, Connecticut Auto Supplement, complies with Connecticut laws and regulations, which require that insureds: * Must be informed of the coverage available under Connecticut’s UM statutes, including both standard UM/UIM and UM Conversion coverage. * Must be permitted to select among various options relating to UM/UIM and UM Conversion Coverage * Connecticut law does not provide for stacking of UM/UIM coverage. The applicant must sign this form, regardless of the coverage selections made. Use with ACORD 90 CT, and allcommercial auto applications.
IDENTIFICATION SECTION Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
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 orcontract number.
IDENTIFICATION SECTION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Carrier Enter text: The insurer’s full legalcompany name(s) as found in thefile 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 NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
ELECTION OF COVERAGE Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
ELECTION OF COVERAGE UM With Standard UIM Coverage Double BI Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected uninsured motorists limits double to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE BI Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected uninsured motorists limits equal to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Minimum Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected the minimum uninsured motorists limits.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE UM Conversion Double BI Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected uninsured motorists limits double to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE BI Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected uninsured motorists limits equal to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Option (checkbox) Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($) Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
ELECTION OF COVERAGE Minimum Limit (checkbox) Check the box (if applicable): Indicates the named insured has selected the minimum uninsured motorists limits.
ELECTION OF COVERAGE Total Coverage Premium ($) Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
SIGNATURE Signature of Any Named Insured Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).