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ACORD 60 HI (2005/01) 1 of 10
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 06/05/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 60 HI (2005/01) |
Hawaii Auto Supplement |
The title of the form. ACORD 60 HI, Hawaii Auto Supplement, complies with Hawaii law. The law requires that every applicant for auto insurance must be provided with information about: * Bodily Injury Liability and Property Damage Liability, Split Limits or Single (Combined) Limits * UM and UIM basic limits and coverage options * Stacking of coverages, and the option of selecting stacked or non-stacked coverages * Personal Injury Protection coverages and Added PIP coverage options * Physical Damage deductibles Use this form with ACORD 90 HI and all commercial auto applications. |
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IDENTIFICATION SECTION |
Producer's name. |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION SECTION |
Sub Code |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Applicant/Named Insured |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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IDENTIFICATION SECTION |
Company |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. |
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IDENTIFICATION SECTION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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SPLIT LIMITS |
Bodily Injury $20,000/$40,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $20,000/$40,000. |
ACORD 60 HI (2005/01) 2 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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SPLIT LIMITS |
Bodily Injury $50,000/$100,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $50,000/$100,000 |
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SPLIT LIMITS |
Bodily Injury $100,000/$300,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $100,000/$300,000 |
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SPLIT LIMITS |
Bodily Injury $300,000/$300,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of $300,000/$300,000 |
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SPLIT LIMITS |
Bodily Injury Fill in amount |
Initial here: The named insured's initials. As used here, indicates the named insured has selected Bodily Injury Limits of Limits other than those listed. |
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SPLIT LIMITS |
$ Bodily Injury Amount |
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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SPLIT LIMITS |
$ Bodily Injury Amount |
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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SPLIT LIMITS |
Bodily Injury Premium |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
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SPLIT LIMITS |
Bodily Injury Premium |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
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SPLIT LIMITS |
Bodily Injury Premium |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
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SPLIT LIMITS |
Bodily Injury Premium |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
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SPLIT LIMITS |
Bodily Injury Premium |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
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SPLIT LIMITS |
Property Damage $10,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $10,000 |
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SPLIT LIMITS |
Property Damage $15,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $15,000 |
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SPLIT LIMITS |
Property Damage $20,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $20,000 |
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SPLIT LIMITS |
Property Damage $30,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $30,000 |
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SPLIT LIMITS |
Property Damage $50,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of $50,000 |
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SPLIT LIMITS |
Property Damage Fill in Amount |
Initial here: The named insured's initials. As used here, indicates the named insured has selected the Property Damage Limit of Limits other than those listed. |
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SPLIT LIMITS |
$ Property Damage Amount |
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
ACORD 60 HI (2005/01) 3 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
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SPLIT LIMITS |
Property Damage Premium |
Enter amount: The property damage premium amount. |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SINGLE LIMITS |
Single Limits $50,000 |
selected a Single Limit of $50,000 |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SINGLE LIMITS |
Single Limits $115,000 |
selected a Single Limit of $115,000 |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SINGLE LIMITS |
Single Limits $320,000 |
selected a Single Limit of $320,000 |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SINGLE LIMITS |
Single Limits Fill in Amount |
selected a Single Limit other than those listed. |
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Enter limit: The vehicle combined single limit liability each accident amount. Any questions |
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about appropriate limits or applicable policy coverage(s) should be answered by the |
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SINGLE LIMITS |
$ Single Limits Amount |
issuing insurer(s). |
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SINGLE LIMITS |
Single Limits Premium |
Enter amount: The vehicle combined single limit liability premium amount. |
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SINGLE LIMITS |
Single Limits Premium |
Enter amount: The vehicle combined single limit liability premium amount. |
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SINGLE LIMITS |
Single Limits Premium |
Enter amount: The vehicle combined single limit liability premium amount. |
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SINGLE LIMITS |
Single Limits Premium |
Enter amount: The vehicle combined single limit liability premium amount. |
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UM &UIM COVERAGE |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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SELECTION / REJECTION |
Reject Both UM &UIM Coverages |
rejects both UM and UIM coverages. |
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UM &UIM COVERAGE |
Reject UM Coverage only, and |
Initial here: The named insured's initials. As used here, indicates the named insured |
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SELECTION / REJECTION |
select UIM Coverage |
rejects UM coverage only, and selects UIM coverage. |
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UM &UIM COVERAGE |
Reject UIM Coverage only, and |
Initial here: The named insured's initials. As used here, indicates the named insured |
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SELECTION / REJECTION |
select UM Coverage |
rejects UIM coverage only, and selects UM coverage. |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits of |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
$20,000-$40,000 |
selected Uninsured Motorists Split Limits of $20,000-$40,000. |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits of |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
$50,000-$100,000 |
selected Uninsured Motorists Split Limits of $50,000-$100,000. |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits of |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
$100,000-$300,000 |
selected Uninsured Motorists Split Limits of $100,000-$300,000. |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits of |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
$300,000-$300,000 |
selected Uninsured Motorists Split Limits of $300,000-$300,000. |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
Other |
selected Uninsured Motorists Split Limits other than those listed. |
ACORD 60 HI (2005/01) 4 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits |
varies by state. (in some states this may contain the combined single limit per accident |
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SELECTION |
Per Person Amount |
limit amount.) |
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Enter limit: The uninsured motorists bodily injury per accident limit (in some states this |
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UM SPLIT LIMITS |
Uninsured Motorists Split Limits |
may contain the uninsured motorists combined single limit per accident limit). The use of |
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SELECTION |
Per Accident Amount |
this limit varies by state. |
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UM SINGLE LIMITS |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
Uninsured Single Limit of $40,000 |
selected an Uninsured Single Limit of $40,000. |
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UM SINGLE LIMITS |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
Uninsured Single Limit of $100,000 |
selected an Uninsured Single Limit of $100,000. |
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UM SINGLE LIMITS |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
Uninsured Single Limit of $300,000 |
selected an Uninsured Single Limit of $300,000. |
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UM SINGLE LIMITS |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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SELECTION |
Uninsured Single Limit Other |
selected an Uninsured Motorists Single other than those listed. |
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UM SINGLE LIMITS |
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SELECTION |
Uninsured Single Limit Amount |
Enter limit: The uninsured motorists combined single limit per accident limit amount. |
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STACKED OR NON |
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STACKED UM & UIM |
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Enter rate: The factor associated with uninsured / underinsured motorists stacked |
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COVERAGE |
Number of Cars 2 Factor |
coverage. As used here, the factor is there are 2 cars. |
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STACKED OR NON |
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STACKED UM & UIM |
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Enter rate: The factor associated with uninsured / underinsured motorists stacked |
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COVERAGE |
Number of Cars 3 Factor |
coverage. As used here, the factor is there are 3 cars. |
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STACKED OR NON |
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STACKED UM & UIM |
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Enter rate: The factor associated with uninsured / underinsured motorists stacked |
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COVERAGE |
Number of Cars 4 Factor |
coverage. As used here, the factor is there are 4 cars. |
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STACKED OR NON |
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STACKED UM & UIM |
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Enter rate: The factor associated with uninsured / underinsured motorists stacked |
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COVERAGE |
Number of Cars 5 Factor |
coverage. As used here, the factor is there are 5 cars. |
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STACKED OR NON |
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STACKED UM & UIM |
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Enter rate: The factor associated with uninsured / underinsured motorists stacked |
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COVERAGE |
Number of Cars 6-8 Factor |
coverage. As used here, the factor is there are 6-8 cars. |
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STACKED OR NON |
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STACKED UM & UIM |
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Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage |
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COVERAGE |
Non-Stacked |
non-stacked. |
ACORD 60 HI (2005/01) 5 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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STACKED OR NON |
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STACKED UM & UIM |
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Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage is |
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COVERAGE |
Stacked |
stacked. |
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ADDED PIP BENEFITS, |
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ADDITIONAL MEDICAL |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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EXPENSE |
$20,000 per person |
selected an APIP limit of $20,000 per person. |
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ADDED PIP BENEFITS, |
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ADDITIONAL MEDICAL |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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EXPENSE |
$30,000 per person |
selected an APIP limit of $30,000 per person. |
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ADDED PIP BENEFITS, |
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ADDITIONAL MEDICAL |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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EXPENSE |
$50,000 per person |
selected an APIP limit of $50,000 per person. |
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ADDED PIP BENEFITS, |
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ADDITIONAL MEDICAL |
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EXPENSE |
APIP per person limit amount. |
Initial here: The named insured's initials. |
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ADDED PIP BENEFITS, |
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ADDITIONAL MEDICAL |
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Enter limit: The additional personal injury protection (APIP) additional medical expense |
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EXPENSE |
$ per person |
limit amount. |
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$500 per month, $3,000 maximum |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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WAGE LOSS BENEFITS |
per accident |
selected Wage Loss Benefits of $500 per month, $3,000 maximum per accident. |
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$1,000 per month, $6,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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WAGE LOSS BENEFITS |
maximum per accident |
selected Wage Loss Benefits of $1,000 per month, $6,000 maximum per accident. |
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$1,500 per month, $9,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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WAGE LOSS BENEFITS |
maximum per accident |
selected Wage Loss Benefits of $1,500 per month, $9,000 maximum per accident. |
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$2,000 per month, $12,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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WAGE LOSS BENEFITS |
maximum per accident |
selected Wage Loss Benefits of $2,000 per month, $12,000 maximum per accident. |
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Initial here: The named insured's initials. As used here, indicates the named insured has |
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WAGE LOSS BENEFITS |
Wage Loss Benefits Other |
selected Wage Loss Benefits with limits other than those listed. |
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Enter limit: The additional personal injury protection (APIP) work/wage loss per month limit |
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WAGE LOSS BENEFITS |
Wage Loss Benefits $ per month |
amount. |
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Wage Loss Benefits $ maximum |
Enter limit: The additional personal injury protection (APIP) work/wage loss per accident |
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WAGE LOSS BENEFITS |
per accident |
limit amount. |
ACORD 60 HI (2005/01) 6 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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DEATH BENEFITS |
Death Benefit $25,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $25,000. |
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DEATH BENEFITS |
Death Benefit $50,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $50,000. |
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DEATH BENEFITS |
Death Benefit $75,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $75,000. |
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DEATH BENEFITS |
Death Benefit $100,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit of $100,000. |
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DEATH BENEFITS |
Death Benefit Other |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Death Benefits limit other than those listed. |
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DEATH BENEFITS |
Death Benefit Limit Amount |
Enter limit: The additional personal injury protection (APIP) accidental death benefit limit amount. |
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FUNERAL EXPENSES |
Funeral Expenses Limit $2,000 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Funeral Expenses Limit of $2,000. |
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FUNERAL EXPENSES |
Funeral Expenses Limit Other |
Initial here: The named insured's initials. As used here, indicates the named insured has selected a Funeral Expenses Limit other than those listed. |
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FUNERAL EXPENSES |
Funeral Expenses Limit |
Enter limit: The limit amount for funeral expense benefit coverage. |
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ALTERNATIVE EXPENSES |
Alternative Expense Maximum $75 per visit, limit 30 visits |
Initial here: The named insured's initials. As used here, indicates the named insured has selected an Alternative Expenses Maximum Limit of $75 per visit, 30 visits. |
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ALTERNATIVE EXPENSES |
Alternative Expense Maximum Other |
Initial here: The named insured's initials. As used here, indicates the named insured has selected an Alternative Expenses Maximum Limit other than those listed. |
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ALTERNATIVE EXPENSES |
Alternative Expense Maximum Per Visit Limit Amount |
Enter limit: The alternate expense maximum per visit limit amount. |
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ALTERNATIVE EXPENSES |
Visits |
Enter number: The alternate expense maximum visits. |
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MANAGED CARE OPTION |
A. I select this option |
Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option through a health maintenance organization (HMO) or a preferred provider organization (PPO). |
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MANAGED CARE OPTION |
B. I agree to a 10% copay, not to exceed $10 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 10% copayment, not to exceed $10. |
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MANAGED CARE OPTION |
I agree to a 20% copay, not to exceed $10 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 20% copayment, not to exceed $10. |
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MANAGED CARE OPTION |
I agree to a 30% copay, not to exceed $10 |
Initial here: The named insured's initials. As used here, indicates the named insured has selected managed care option with a 30% copayment, not to exceed $10. |
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MANAGED CARE OPTION |
C. I agree to a $100 deductible |
Initial here: The named insured's initials. As used here, indicates the named insured agrees to a $100 managed care option deductible. |
ACORD 60 HI (2005/01) 7 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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MANAGED CARE OPTION |
C. I agree to a $300 deductible |
agrees to a $300 managed care option deductible. |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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MANAGED CARE OPTION |
C. I agree to a $500 deductible |
agrees to a $500 managed care option deductible. |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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MANAGED CARE OPTION |
C. I agree to a $1,000 deductible |
agrees to a $1,000 managed care option deductible. |
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PERSONAL INJURY |
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PROTECTION CO |
I agree to a 10% co-payment |
Initial here: The named insured's initials. As used here, indicates the named insured |
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PAYMENT OPTION |
option for PIP coverage |
agrees to a Personal Injury Protection Co-payment option of 10%. |
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PERSONAL INJURY |
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PROTECTION CO |
I agree to a 20% co-payment |
Initial here: The named insured's initials. As used here, indicates the named insured |
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PAYMENT OPTION |
option for PIP coverage |
agrees to a Personal Injury Protection Co-payment option of 20%. |
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PERSONAL INJURY |
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PROTECTION CO |
I agree to a 30% co-payment |
Initial here: The named insured's initials. As used here, indicates the named insured |
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PAYMENT OPTION |
option for PIP coverage |
agrees to a Personal Injury Protection Co-payment option of 30%. |
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PERSONAL INJURY |
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PROTECTION |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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DEDUCTIBLES |
I agree to a deductible of $100 |
agrees to a Personal Injury Protection Deductible of $100. |
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PERSONAL INJURY |
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PROTECTION |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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DEDUCTIBLES |
I agree to a deductible of $300 |
agrees to a Personal Injury Protection Deductible of $300. |
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PERSONAL INJURY |
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PROTECTION |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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DEDUCTIBLES |
I agree to a deductible of $500 |
agrees to a Personal Injury Protection Deductible of $500. |
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PERSONAL INJURY |
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PROTECTION |
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Initial here: The named insured's initials. As used here, indicates the named insured |
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DEDUCTIBLES |
I agree to a deductible of $1,000 |
agrees to a Personal Injury Protection Deductible of $1,000. |
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PERSONAL INJURY |
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PROTECTION |
I agree to a deductible of fill in |
Initial here: The named insured's initials. As used here, indicates the named insured |
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DEDUCTIBLES |
amount |
agrees to a Personal Injury Protection Deductible other than those listed. |
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PERSONAL INJURY |
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PROTECTION |
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DEDUCTIBLES |
PIP Deductible Amount |
Enter deductible: The deductible amount for personal injury protection (PIP) coverage. |
ACORD 60 HI (2005/01) 8 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $50 |
selected a comprehensive deductible of $50. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $100 |
selected a comprehensive deductible of $100. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $250 |
selected a comprehensive deductible of $250. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $500 |
selected a comprehensive deductible of $500. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $1000 |
selected a comprehensive deductible of $1,000. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $1500 |
selected a comprehensive deductible of $1,500. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
comprehensible deductible $2000 |
selected a comprehensive deductible of $2,000. |
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PHYSICAL DAMAGE |
I select the following |
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COMPREHENSIVE & |
comprehensible deductible fill in |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
amount |
selected a comprehensive deductible other than those listed. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
Comprehensive Deductible |
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COLLISION DEDUCTIBLES |
Amount |
Enter deductible: The comprehensive or other than collision deductible amount. |
ACORD 60 HI (2005/01) 9 of 10
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Section Name |
Field Name |
Field and/or Section Description |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
deductible $50 |
selected a collision deductible of $50. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
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COLLISION DEDUCTIBLES |
deductible $100 |
selected a collision deductible of $100. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
deductible $250 |
selected a collision deductible of $250. |
|
PHYSICAL DAMAGE |
|
|
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
deductible $500 |
selected a collision deductible of $500. |
|
PHYSICAL DAMAGE |
|
|
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
deductible $1000 |
selected a collision deductible of $1,000. |
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PHYSICAL DAMAGE |
|
|
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COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
deductible $1500 |
selected a collision deductible of $1,500. |
|
PHYSICAL DAMAGE |
|
|
|
COMPREHENSIVE & |
I select the following collision |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
deductible $2000 |
selected a collision deductible of $2,000. |
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PHYSICAL DAMAGE |
I select the following |
|
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COMPREHENSIVE & |
comprehensible deductible fill in |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
COLLISION DEDUCTIBLES |
amount |
selected a collision deductible other than those listed. |
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PHYSICAL DAMAGE |
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COMPREHENSIVE & |
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|
|
COLLISION DEDUCTIBLES |
Collision Deductible Amount |
Enter deductible: The collision deductible amount. |
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Section Name |
Field Name |
Field and/or Section Description |
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SIGNATURE |
Applicants Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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EDITION |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 60 HI (2005/01) 10 of 10
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