ACORD 60 HI (2010/07)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 60 HI (2010/07)
Hawaii Auto Supplement
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.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
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.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
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.
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Section Name
Field Name
Field and/or Section Description
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
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
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
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.
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).
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).
SPLIT LIMITS
Bodily Injury Premium
Enter amount: The vehicle policy, bodily injury per accident premium amount.
SPLIT LIMITS
Bodily Injury Premium
Enter amount: The vehicle policy, bodily injury per accident premium amount.
SPLIT LIMITS
Bodily Injury Premium
Enter amount: The vehicle policy, bodily injury per accident premium amount.
SPLIT LIMITS
Bodily Injury Premium
Enter amount: The vehicle policy, bodily injury per accident premium amount.
SPLIT LIMITS
Bodily Injury Premium
Enter amount: The vehicle policy, bodily injury per accident premium amount.
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
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
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
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
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
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.
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).
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
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Section Name
Field Name
Field and/or Section Description
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
SPLIT LIMITS
Property Damage Premium
Enter amount: The property damage premium amount.
SINGLE LIMITS
Single Limits $50,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a Single Limit of $50,000
SINGLE LIMITS
Single Limits $115,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a Single Limit of $115,000
SINGLE LIMITS
Single Limits $320,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a Single Limit of $320,000
SINGLE LIMITS
Single Limits Fill in Amount
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a Single Limit other than those listed.
SINGLE LIMITS
$ Single Limits Amount
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
SINGLE LIMITS
Single Limits Premium
Enter amount: The vehicle combined single limit liability premium amount.
SINGLE LIMITS
Single Limits Premium
Enter amount: The vehicle combined single limit liability premium amount.
SINGLE LIMITS
Single Limits Premium
Enter amount: The vehicle combined single limit liability premium amount.
SINGLE LIMITS
Single Limits Premium
Enter amount: The vehicle combined single limit liability premium amount.
UM &UIM COVERAGE
SELECTION / REJECTION
Reject Both UM &UIM Coverages
Initial here: The named insured's initials. As used here, indicates the named insured
rejects both UM and UIM coverages.
UM &UIM COVERAGE
SELECTION / REJECTION
Reject UM Coverage only, and
select UIM Coverage
Initial here: The named insured's initials. As used here, indicates the named insured
rejects UM coverage only, and selects UIM coverage.
UM &UIM COVERAGE
SELECTION / REJECTION
Reject UIM Coverage only, and
select UM Coverage
Initial here: The named insured's initials. As used here, indicates the named insured
rejects UIM coverage only, and selects UM coverage.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits of
$20,000-$40,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Uninsured Motorists Split Limits of $20,000-$40,000.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Premium
Enter amount: The uninsured motorist split limit premium amount.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits of
$50,000-$100,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Uninsured Motorists Split Limits of $50,000-$100,000.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Premium
Enter amount: The uninsured motorist split limit premium amount.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits of
$100,000-$300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Uninsured Motorists Split Limits of $100,000-$300,000.
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Section Name
Field Name
Field and/or Section Description
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Premium
Enter amount: The uninsured motorist split limit premium amount.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits of
$300,000-$300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Uninsured Motorists Split Limits of $300,000-$300,000.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Premium
Enter amount: The uninsured motorist split limit premium amount.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Other
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Uninsured Motorists Split Limits other than those listed.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Per Person Amount
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Per Accident Amount
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
UM SPLIT LIMITS
SELECTION
Uninsured Motorists Split Limits
Premium
Enter amount: The uninsured motorist split limit premium amount.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit of $40,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Uninsured Single Limit of $40,000.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Premium
Enter amount: The uninsured motorist combined single limit premium amount.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit of $100,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Uninsured Single Limit of $100,000.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Premium
Enter amount: The uninsured motorist combined single limit premium amount.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit of $300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Uninsured Single Limit of $300,000.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Premium
Enter amount: The uninsured motorist combined single limit premium amount.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Other
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Uninsured Motorists Single other than those listed.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Amount
Enter limit: The uninsured motorists combined single limit per accident limit amount.
UM SINGLE LIMITS
SELECTION
Uninsured Single Limit Premium
Enter amount: The uninsured motorist combined single limit premium amount.
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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Section Name
Field Name
Field and/or Section Description
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits of $20,000-$40,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Split Limits of $20,000-$40,000.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Premium
Enter amount: The underinsured motorist split limit premium amount.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits of $50,000-$100,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Split Limits of $50,000-$100,000.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Premium
Enter amount: The underinsured motorist split limit premium amount.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits of $100,000-$300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Underinsured Motorists Split Limits of $100,000-$300,000.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Premium
Enter amount: The underinsured motorist split limit premium amount.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits of $300,000-$300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Split Limits of $300,000-$300,000.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Premium
Enter amount: The underinsured motorist split limit premium amount.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Other
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Underinsured Motorists Split Limits other than those listed.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Per Person Amount
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Per Accident Amount
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
UIM SPLIT LIMITS
SELECTION
Underinsured Motorists Split
Limits Premium
Enter amount: The underinsured motorist split limit premium amount.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit of
$40,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Underinsured Single Limit of $40,000.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit
Premium
Enter amount: The underinsured motorist combined single limit premium amount.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit of
$100,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Underinsured Single Limit of $100,000.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit
Premium
Enter amount: The underinsured motorist combined single limit premium amount.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit of
$300,000
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Underinsured Single Limit of $300,000.
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Section Name
Field Name
Field and/or Section Description
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit
Premium
Enter amount: The underinsured motorist combined single limit premium amount.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit Other
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an Underinsured Motorists Single other than those listed.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit Amount
Enter limit: The underinsured motorists combined single limit per accident limit amount.
UIM SINGLE LIMITS
SELECTION
Underinsured Single Limit
Premium
Enter amount: The underinsured motorist combined single limit premium amount.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Number of Cars 2 Factor
Enter rate: The factor associated with uninsured / underinsured motorists stacked
coverage. As used here, the factor is there are 2 cars.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Number of Cars 3 Factor
Enter rate: The factor associated with uninsured / underinsured motorists stacked
coverage. As used here, the factor is there are 3 cars.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Number of Cars 4 Factor
Enter rate: The factor associated with uninsured / underinsured motorists stacked
coverage. As used here, the factor is there are 4 cars.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Number of Cars 5 Factor
Enter rate: The factor associated with uninsured / underinsured motorists stacked
coverage. As used here, the factor is there are 5 cars.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Number of Cars 6-8 Factor
Enter rate: The factor associated with uninsured / underinsured motorists stacked
coverage. As used here, the factor is there are 6-8 cars.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Non-Stacked
Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage
non-stacked.
STACKED OR NON-
STACKED UM & UIM
COVERAGE
Stacked
Check the box (if applicable): Indicates the uninsured / underinsured motorists coverage is
stacked.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
ADDED PIP BENEFITS,
ADDITIONAL MEDICAL
EXPENSE
$20,000 per person
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an APIP limit of $20,000 per person.
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Section Name
Field Name
Field and/or Section Description
ADDED PIP BENEFITS,
ADDITIONAL MEDICAL
EXPENSE
$30,000 per person
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an APIP limit of $30,000 per person.
ADDED PIP BENEFITS,
ADDITIONAL MEDICAL
EXPENSE
$50,000 per person
Initial here: The named insured's initials. As used here, indicates the named insured has
selected an APIP limit of $50,000 per person.
ADDED PIP BENEFITS,
ADDITIONAL MEDICAL
EXPENSE
APIP per person limit amount.
Initial here: The named insured's initials.
ADDED PIP BENEFITS,
ADDITIONAL MEDICAL
EXPENSE
$ per person
Enter limit: The additional personal injury protection (APIP) additional medical expense
limit amount.
WAGE LOSS BENEFITS
$500 per month, $3,000 maximum
per accident
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Wage Loss Benefits of $500 per month, $3,000 maximum per accident.
WAGE LOSS BENEFITS
$1,000 per month, $6,000
maximum per accident
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Wage Loss Benefits of $1,000 per month, $6,000 maximum per accident.
WAGE LOSS BENEFITS
$1,500 per month, $9,000
maximum per accident
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Wage Loss Benefits of $1,500 per month, $9,000 maximum per accident.
WAGE LOSS BENEFITS
$2,000 per month, $12,000
maximum per accident
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Wage Loss Benefits of $2,000 per month, $12,000 maximum per accident.
WAGE LOSS BENEFITS
Wage Loss Benefits Other
Initial here: The named insured's initials. As used here, indicates the named insured has
selected Wage Loss Benefits with limits other than those listed.
WAGE LOSS BENEFITS
Wage Loss Benefits $ per month
Enter limit: The additional personal injury protection (APIP) work/wage loss per month limit
amount.
WAGE LOSS BENEFITS
Wage Loss Benefits $ maximum
per accident
Enter limit: The additional personal injury protection (APIP) work/wage loss per accident
limit amount.
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.
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.
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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Section Name
Field Name
Field and/or Section Description
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.
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.
DEATH BENEFITS
Death Benefit Limit Amount
Enter limit: The additional personal injury protection (APIP) accidental death benefit limit
amount.
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.
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.
FUNERAL EXPENSES
Funeral Expenses Limit
Enter limit: The limit amount for funeral expense benefit coverage.
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.
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.
ALTERNATIVE EXPENSES
Alternative Expense Maximum Per
Visit Limit Amount
Enter limit: The alternate expense maximum per visit limit amount.
ALTERNATIVE EXPENSES
Visits
Enter number: The alternate expense maximum visits.
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).
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.
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.
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.
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.
MANAGED CARE OPTION
C. I agree to a $300 deductible
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a $300 managed care option deductible.
MANAGED CARE OPTION
C. I agree to a $500 deductible
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a $500 managed care option deductible.
MANAGED CARE OPTION
C. I agree to a $1,000 deductible
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a $1,000 managed care option deductible.
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Section Name
Field Name
Field and/or Section Description
PERSONAL INJURY
PROTECTION CO-
PAYMENT OPTION
I agree to a 10% co-payment
option for PIP coverage
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Co-payment option of 10%.
PERSONAL INJURY
PROTECTION CO-
PAYMENT OPTION
I agree to a 20% co-payment
option for PIP coverage
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Co-payment option of 20%.
PERSONAL INJURY
PROTECTION CO-
PAYMENT OPTION
I agree to a 30% co-payment
option for PIP coverage
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Co-payment option of 30%.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
I agree to a deductible of $100
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Deductible of $100.
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
I agree to a deductible of $300
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Deductible of $300.
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
I agree to a deductible of $500
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Deductible of $500.
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
I agree to a deductible of $1,000
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Deductible of $1,000.
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
I agree to a deductible of fill in
amount
Initial here: The named insured's initials. As used here, indicates the named insured
agrees to a Personal Injury Protection Deductible other than those listed.
PERSONAL INJURY
PROTECTION
DEDUCTIBLES
PIP Deductible Amount
Enter deductible: The deductible amount for personal injury protection (PIP) coverage.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $50
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $50.
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Section Name
Field Name
Field and/or Section Description
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $100
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $100.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $250
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $250.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $500
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $500.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $1000
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $1,000.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $1500
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $1,500.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES comprehensible deductible $2000
I select the following
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible of $2,000.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES amount
I select the following
comprehensible deductible fill in
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a comprehensive deductible other than those listed.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES Amount
Comprehensive Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $50
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $50.
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Section Name
Field Name
Field and/or Section Description
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $100
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $100.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $250
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $250.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $500
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $500.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $1000
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $1,000.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $1500
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $1,500.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES deductible $2000
I select the following collision
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible of $2,000.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES amount
I select the following
comprehensible deductible fill in
Initial here: The named insured's initials. As used here, indicates the named insured has
selected a collision deductible other than those listed.
PHYSICAL DAMAGE
COMPREHENSIVE &
COLLISION DEDUCTIBLES Collision Deductible Amount
Enter deductible: The collision deductible amount.
SIGNATURE
Applicants Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
EDITION
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 60 HI (2010/07) rev. 07-30-2010
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