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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 07/10/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 60 PA (2008/01) |
Pennsylvania Auto Supplement, Uninsured Motorists Coverage, Selection/Rejection |
The title of the form. ACORD 60 PA, Pennsylvania Auto Supplement, Uninsured Motorists Coverage, Selection/Rejection, is used for selection or rejection of Uninsured Motorists Coverage. According to Pennsylvania law, this form must be separate from any other form. Use ACORD 60 PA with 90 PA, and all commercial auto applications. Although this form has been filed and approved by the Pennsylvania Insurance Department, the Department requires that insurers using this form must notify the Department that they are doing so. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Applicant (First Name Insured) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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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 |
Carrier |
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 |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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SELECTION OF UNINSURED MOTORISTS PROTECTION |
The Uninsured Motorists coverage limits I select are: ($) |
Enter limit: The uninsured motorists combined single limit per accident limit amount. |
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SIGNATURE |
Signature of First Named Insured |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the first named insured must sign their selection. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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SIGNATURE |
Reject Uninsured Motorist Protection Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the first named insured must sign their rejection. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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Section Name |
Field Name |
Field and/or Section Description |
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SIGNATURE |
1. Retain stacking of Uninsured Motorist Coverage Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the first named insured must sign their selection. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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REJECT STACKING |
2. Reject stacking Uninsured Motorist Coverage Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the first named insured must sign their selection. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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SIGNATURE |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
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SIGNATURE |
Effective Date |
Enter date: The effective date of the uninsured motorists coverage. |
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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). |