ACORD 62FL Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 62 FL (2008/03) Florida Auto Supplement -Personal Injury Protection Options ACORD 62 FL, Florida Auto Supplement, Personal Injury Protection Options, complies with Florida law, 627.739 which requires that for personal injury protection insurance, the named insured may elect a deductible and exclude coverage for loss of gross income and loss of earning capacity (lost wages). These elections may apply to the named insured alone, or to the named insured and all dependent relatives residing in the same household. Use with ACORD 90 FL, and any commercial auto application.
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 the insurance company for the policy. In general, policy numbers will not appear on newbusiness 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.
PERSONAL INJURYPROTECTION OPTIONS I hereby elect a deductible of Enter the desired deductible. Enter “0” if no deductible is desired. Corporations must select “0”.
PERSONAL INJURY PROTECTION OPTIONS Choose one: This deductible applies to the named insured only Check the applicable box
PERSONAL INJURY PROTECTION OPTIONS Choose one: This deductible applies to the named insured and all dependent resident relatives Check the applicable box
PERSONAL INJURY PROTECTION OPTIONS I hereby elect to exclude coverage for loss of gross income and loss of earning capacity Check the applicable box
PERSONAL INJURY PROTECTION OPTIONS Choose one: This election applies to the named insured only Check the applicable box
PERSONAL INJURY PROTECTION OPTIONS Choose one: This election applies to the named insured and all dependent resident relatives Check the applicable box
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 PIP deductible election and/or exclusion of coverage for loss of gross income and earning capacity. (MM/DD/YYYY)