| Section Name | Field Name | Field and/or Section Description |
| ACORD 62 PA, Pennsylvania Auto Supplement, Underinsured Motorists Coverage, Selection/Rejection, provides for selection or rejection of Underinsured Motorists Coverage. | ||
| According to Pennsylvania law, this form must be separate from any other form. | ||
| TITLE ACORD 62 PA (2008/01) | Pennsylvania Auto Supplement, Underinsured Motorists Coverage, Selection/Rejection | Use ACORD 62 PA with 90 PA, and all commercial auto applications. The Pennsylvania Insurance Department no longer requires insurers using this form to file it with the Department before use. |
| 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). |
| 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. |
| SELECTION OF | ||
| UNDERINSURED | The underinsured motorists | |
| MOTORISTS PROTECTION | coverage limits I select are: $ | Indicate the desired limit. |
| SELECTION OF | ||
| UNDERINSURED | ||
| MOTORISTS PROTECTION | Signature of First Named Insured | First Named Insured must sign their selection. |
| SELECTION OF UNDERINSURED MOTORISTS PROTECTION | Date | Indicate the date signed. (MM/DD/YYYY) |
| REJECTION OF UNDERINSURED MOTORISTS PROTECTION | Signature of First Named Insured | First Named Insured must sign their rejection. |
| REJECTION OF UNDERINSURED MOTORISTS PROTECTION | Date | Indicate the date signed. (MM/DD/YYYY) |
| UNDERINSURED COVERAGE LIMITS | I want to retain stacking of my Underinsured Motorists Coverage | First Named Insured must sign their selection. |
| UNDERINSURED COVERAGE LIMITS | Date | Indicate the date signed. (MM/DD/YYYY) |
| UNDERINSURED COVERAGE LIMITS | I want to reject stacking and choose non-stacked Underinsured Motorists Coverage | First Named Insured must sign their selection. |
| UNINSURED COVERAGE LIMITS | Date | Indicate the date signed. (MM/DD/YYYY) |
| SIGNATURE | Applicant’s Signature | Applicant must sign the application. |
| SIGNATURE | Effective Date | Indicate the effective date of the underinsured motorists coverage. |
| SIGNATURE | Date | Indicate the date signed. (MM/DD/YYYY) |