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ACORD 61 CA Instructions
 

 
Section Name Field Name Field and/or Section Description
ACORD 61 CA, California Auto Supplement, Mandatory Uninsured Motorists Bodily Injury Coverage Offer, complies with California law and regulations, which require that the insured:
* Must be offered Uninsured Motorists Bodily Injury (UMBI) coverage up to the limits of Bodily Injury coverage in the policy;
* Can reject UMBI completely, or can reject UMBI with respect to individual drivers
* Can select UMBI limit(s) which are lower than the policy limits for Bodily Injury, but not lower than the financial responsibility requirements.
* Must be offered Uninsured Motorists Property Damage (UMPD) coverage
* Can select UMPD at a limit of $3,500
* Can reject UMPD completely, or can reject UMPD with respect to individual drivers
TITLE ACORD 61 CA (2008/03) California Auto Supplement, Mandatory Uninsured Motorists Bodily Injury Coverage Offer Any of these selection/rejection options must be agreed to in writing by the insured. Use this form with ACORD 90 CA, and all commercial auto applications, unless the applicant selects UMBI limits at the policy's BI coverage limit(s).
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency Producer's name.
The number assigned by the insurance company for the policy. In general, policy numbers
IDENTIFICATION SECTION Policy Number will not appear on new business applications 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.

ACORD 61 CA (2008/03) 1 of 3 ACORD 61 CA (2008/03) 2 of 3 ACORD 61 CA (2008/03) 3 of 3

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Applicant / Named Insured(s) 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).
REJECTION OF UMBI Applicant must sign his/her initials if they reject Uninsured Motorists Bodily Injury
COVERAGE I reject UMBI coverage entirely Coverage entirely.
REJECTION OF UMBI I reject UMBI coverage only with Applicant must sign his/her initials if they reject Uninsured Motorists Bodily Injury
COVERAGE respect to the following: Coverage for individual selected drivers.
REJECTION OF UMBI Provide the names of the drivers who should be excluded from Uninsured Motorists Bodily
COVERAGE Name(s) of Excluded Driver(s) Injury coverage.
I select UMBI coverage limits
LOWER LIMITS FOR UMBI which are lower than my bodily Applicant must sign his/her initials if they select UMBI coverage limits which are lower than
COVERAGE injury limits their bodily injury limits.
LOWER LIMITS FOR UMBI
COVERAGE $ Provide the desired limit.
SIGNATURE Applicant's Signature Applicant/Named Insured must sign the application.
DATE Date Date the application was completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
MANDATORY UMPD I select UMPD coverage at a limit Applicant must sign his/her initials if they select UMPD coverage at a limit of $3,500 for
COVERAGE OFFER of $3,500 for each accident each accident. Applicant must identify the covered vehicles in the space provided.
MANDATORY UMPD
COVERAGE OFFER Year Indicate the year of the motor vehicle.
MANDATORY UMPD
COVERAGE OFFER Make Indicate the make of the motor vehicle. (e.g., Ford)
MANDATORY UMPD
COVERAGE OFFER Model Indicate the model of the motor vehicle. (e.g., Taurus)
MANDATORY UMPD Applicant must sign his/her initials if they reject Uninsured Motorists Property Damage
COVERAGE OFFER I reject UMPD coverage entirely Coverage entirely.
I reject UMPD coverage only with
MANDATORY UMPD respect to the following Applicant must sign his/her initials if they reject Uninsured Motorists Property Damage
COVERAGE OFFER individuals: Coverage for individual selected drivers.
Section Name Field Name Field and/or Section Description
MANDATORY UMPD COVERAGE OFFER Name(s) of Excluded Driver(s) Provide the names of the drivers who should be excluded from Uninsured Motorists Property Damage coverage.
SIGNATURE Applicant's Signature Applicant/Named Insured must sign the application.
DATE Date Date the application was completed. (MM/DD/YYYY)
SIGNATURE Effective Date Enter the effective date of the Uninsured Motorists coverage selection/rejection. (MM/DD/YYYY)