| Section Name | Field Name | Field and/or Section Description |
| Georgia Auto Supplement – | ACORD 62 GA, Uninsured Motorists Optional Coverage Disclosure, complies with Georgia law. Use this form with all applications for personal and commercial auto | |
| TITLE | Uninsured Motorists Optional | insurance as well as renewals. The language in this form has been provided by the |
| ACORD 62 GA (2008/01) | Coverage Disclosure | Commissioner of Insurance. |
| IDENTIFICATION SECTION | Agency Customer ID | Customer’s identification number assigned by the agency or brokerage. |
| IDENTIFICATION SECTION | Agency | Producer’s name. |
| IDENTIFICATION SECTION | Applicant / Named 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). |
| The number assigned by theinsurance company for the policy. In general, policy numbers | ||
| IDENTIFICATION SECTION | Policy Number | will not appear on new businessapplications since they are not known at that point in time. |
| 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 | ||
| IDENTIFICATION SECTION | Carrier | you wish to have the policy issued. |
| IDENTIFICATION SECTION | NAIC Code | The identification code assigned to the company by the NAIC. |
| SIGNATURE | Applicant’s Signature | Applicant/Named Insured must sign the application. |
| SIGNATURE | Date | Date the application was completed. (MM/DD/YYYY) |