ACORD 61FL Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 61 FL (2008/03) Florida Auto Supplement -Rejection/Election of UM Coverage ACORD 61 FL, Florida Auto Supplement – Rejection/Election of UM Coverage, complies with Florida law, which requires that every applicant forauto insurance: * Must receive an explanation of Uninsured Motorists (UM) coverage * Must be offered UM coverage equal to the bodily Injury limits in the policy * Must be allowed to select lower limits or reject UM coverage entirely * If accepting UM coverage, can elect non-stacked coverage This form must be signed by the applicant, if Uninsured Motorists coverage less than the policy’s Bodily Injury Liability limit(s) is selected or rejected, or if, non-stacked coverage is selected. If UM coverage less than the policy’s Bodily Injury Liability limit(s) is selected, the applicant must initial the limits specified.
Use with ACORD 90 FL, and any commercial autoapplication. In addition, Florida requires that Uninsured Motorists coverage must be offered in umbrella policies when auto liability coverage is included. Use ACORD 61 FL with personal and commercial umbrella applications.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency Producer’s name.
IDENTIFICATION SECTION Applicant (First Name Insured) 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).
IDENTIFICATION SECTION Policy Number The number assigned by theinsurance company for the policy. In general, policy numbers will not appear onnew business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier 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.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
REJECTION/SELECTION I reject Uninsured Motorists coverage entirely Applicant/Named Insured must initial his/her rejection of Uninsured Motorists coverage.
REJECTION/SELECTION I select Uninsured Motorists limits of $ which are lower than my bodily injury limits Applicant/Named Insured must initial his/her selection of Uninsured Motorists limits which are lower than his/her bodily injury limits.
REJECTION/SELECTION $ Indicate the desired limits.
SIGNATURE Applicant’s Signature Applicant/Named Insured must sign the application.
SIGNATURE Date Date the application wascompleted. (MM/DD/YYYY)
SIGNATURE Effective Date Enter the effective date of the Uninsured Motorists coverage selection/rejection.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
ELECTION OF NONSTACKED COVERAGE I elect the non-stacked form of Uninsured Motorists coverage Applicant/Named Insured must initial his/her selection of the non-stacked Uninsured Motorists coverage.
SIGNATURE Applicant’s Signature Applicant/Named Insured must sign the application.
SIGNATURE Date Date the application was completed. (MM/DD/YYYY)
SIGNATURE Effective Date Enter the effective date of the Uninsured Motorists coverage selection/rejection. (MM/DD/YYYY)