Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 60 PA (2012/10)
Pennsylvania Auto Supplement,
Uninsured Motorist Coverage
Selection / Rejection
ACORD 60 PA, Pennsylvania Auto Supplement, Uninsured Motorist
Coverage Selection / Rejection, is used for selection or rejection of Uninsured Motorist
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.
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
Applicant (First Name Insured)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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
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.
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.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SELECTION OF
UNINSURED MOTORIST
PROTECTION
The uninsured motorist coverage
limits I select are: ($)
Enter limit: The uninsured motorists combined single limit per accident limit amount.
SELECTION OF
UNINSURED MOTORIST
PROTECTION
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.)
ACORD 60 PA (2012/10) rev. 09-28-2012
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Section Name
Field Name
Field and/or Section Description
SELECTION OF
UNINSURED MOTORIST
PROTECTION
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.
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.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Effective Date
Enter date: The effective date of the uninsured motorists coverage.
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 PA (2012/10) rev. 09-28-2012
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