ACORD 67 MD (2005/01) – Maryland Personal Auto Supplement – Mandatory Offer of Increased Liability Coverage for Claims of Family Members at an Additional Premium (New Business), MandatoryPersonal Injury Protection Waiver, and Mandatory Uninsured Motorist Coverage Waiver for Private Passenger Motor Vehicle Liability Insurance in the State of Maryland
This form complies with Maryland law and the Maryland Insurance Administration’s Bulletin P/C 04-18-A. It must be provided to all applicants for personal auto insurance.
The form consists of three (3) parts:
Part 1: Offer of Increased Liability Coverage for Claims of Family Members (New Business)
Part 2: Notice and Waiver of Personal Injury Protection (PIP) Coverage
Part 3: Notice and Waiver of Increased Limits of Uninsured Motorist Coverage
All three parts of the form must be signed and dated whether the insured accepts or rejects them. The executed original of this form or a reliable image thereof by way of photographic, microprocessed, magnetic, mechanical, electronic, digital or any other media that the company uses to maintain its records of insurance transactions should be kept with the original application.
A copy of this form becomes a part of and must be attached to the policy if one or more parts are waived or requested – unless an endorsement is attached to the policy reflecting the insured’s choices.
Use this form with ACORD 90 MD.