ACORD 67UT Instructions

ACORD 67 UT (10/94) – Utah Auto Insurance Supplement,Personal Injury Protection Coverage, Waiver of Loss of Income Benefits

A 1994 Utah law provides for an option that allows the named insured to waive, for the named insured and the named insured’s spouse only, coverage for Income Benefits under Personal Injury Protection insurance.

This coverage can be waived only if both the named insured and the named insured’s spouse have had no earned income from regularemployment within the 31 days prior to applying for auto insurance, and will have no such income during the next 180 days, or the policy period, whichever is longer.

The Utah Insurance Department requires that current insureds and new insureds must be advised of this option, and that an adequate description of the option must be provided.

Use ACORD 67 UT with all personal and commercial auto applications. This form can also be used to notify current insureds of the available option.