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ACORD Form 62 FL Florida Auto Supplement - Personal Injury Protection Instructions
 

 
Section Name Field Name Field and/or Section Description
ACORD 62 FL, Florida Auto Supplement, Personal Injury Protection (No-Fault Coverage)
Options, complies with Florida law, 627.739 which requires that for personal injury
protection insurance, the named insured may elect a deductible and exclude coverage for
loss of gross income and loss of earning capacity ("lost wages" or "work loss"). These
elections may apply to the named insured alone, or to the named insured and all
Florida Auto Supplement - dependent relatives residing in the same household.
TITLE Personal Injury Protection (No- Use with ACORD 90 FL, and any commercial auto application where the named insured is
ACORD 62 FL (2008/06) Fault Coverage) Options designated as an individual in the Declaration of the auto policy.
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.
IDENTIFICATION SECTION 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).
OPTION I. PERSONAL I do not want a deductible to apply
INJURY PROTECTION to my policy's Personal Injury
OPTIONS Protection coverage. Check this box if a deductible is not desired.
OPTION I. PERSONAL
INJURY PROTECTION I hereby elect the deductible Check this box if a deductible is desired. Indicate to whom the deductible applies by
OPTIONS indicated below. checking the applicable box.
OPTION I. PERSONAL
INJURY PROTECTION
OPTIONS Named Insured This deductible applies to the named insured only

ACORD 62 FL (2008/06) 1 of 2 ACORD 62 FL (2008/06) 2 of 2

Section Name Field Name Field and/or Section Description
OPTION I. PERSONAL
INJURY PROTECTION Named Insured and All Dependent
OPTIONS Resident Relatives This deductible applies to the named insured and all dependent resident relatives.
Exclude Work Loss benefits for
OPTION II. EXCLUSION OF the Named Insured and All Check this box if the exclusion of work loss benefits applies to the named insured and all
WORK LOSS BENEFITS Dependent Resident Relatives. dependent resident relatives.
OPTION II. EXCLUSION OF Exclude Work Loss benefits for
WORK LOSS BENEFITS the Named Insured Only Check this box if the exclusion of work loss benefits applies to the named insured only.
SIGNATURE Applicant's Signature Applicant/Named Insured must sign the application.
SIGNATURE Date Date the application was completed. (MM/DD/YYYY)
Enter the effective date of the PIP deductible election and/or exclusion of work loss
SIGNATURE Effective Date benefits. (MM/DD/YYYY)