ACORD 61 FL (2011/10) - FLORIDA COMMERCIAL AUTO SUPPLEMENT
ACORD 61 FL (2011/10) - FLORIDA COMMERCIAL AUTO SUPPLEMENT
ACORD 61 FL, Florida Commercial Auto Supplement - Rejection / Election of Uninsured Motorist Coverage, complies with Florida law, which
requires that every applicant for auto insurance:
* Must receive an explanation of Uninsured Motorists (UM) coverage
* Must be offered Uninsured Motorist (UM) coverage equal to the bodily Injury limits in the policy
* Must be allowed to select lower limits or reject UM coverage entirely
* If accepting UM coverage, can elect non-stacked coverage
This form must be signed by the applicant if Uninsured Motorist coverage less than the policy's Bodily Injury Liability limit(s) is selected or UM is
rejected entirely; or if, non-stacked coverage is selected. If UM coverage less than the policy's Bodily Injury Liability limit(s) is selected or UM is
rejected entirely, or if, non-stacked coverage is selected, the applicant must initial. Use with any commercial auto application where the named
insured is designated as an individual in the Declaration of the auto policy.
In addition, Florida requires that Uninsured Motorist coverage must be offered in umbrella policies when auto liability coverage is included. Use
ACORD 61 FL with commercial umbrella applications where the named insured is designated as an individual in the Declaration of the policy.
Form Page 1
Section Name
Field Name
Description
SELECTION / REJECTION
OF UNINSURED MOTORIST
COVERAGE
Policy will include
specifically insured or
identified motor vehicle(s)
registered or principally
garaged in Florida
(checkbox)
Check the box (if applicable): Policy will include specifically insured or identified motor vehicle(s)
registered or principally garaged in Florida.
SELECTION / REJECTION
OF UNINSURED MOTORIST
COVERAGE
Uninsured Motorist
coverage is desired for
other than specifically
insured or identified motor
vehicles(s) registered or
principally garaged in
Florida (checkbox)
Check the box (if applicable): Uninsured Motorist coverage is desired for other than specifically
insured or identified motor vehicles(s) registered or principally garaged in Florida.
SECTION A
I reject Uninsured Motorist
Coverage entirely
(checkbox)
Check the box (if applicable): Indicates uninsured motorists coverage has been rejected by the
named insured.
ACORD 61 FL (2011/10) rev. 12-17-2014
Page 1 of 4
SECTION A
I select Uninsured Motorist
limit(s) equal to my Bodily
Injury Liability (checkbox)
Check the box (if applicable): Indicates the named insured has selected uninsured motorists
coverage limits listed. As used here, indicates the named insured has selected Uninsured
Motorist limits(s) equal to the Bodily Injury Liability Limits or Combined Single Limit for Liability
Coverage.
SECTION A
I select the following
Uninsured Motorist
Coverage limit(s) listed on
page 2 (checkbox)
Check the box (if applicable): Indicates the named insured has selected uninsured motorists
coverage limits listed. As used here, indicates the named insured has selected Uninsured
Motorist limits(s) lower than the Bodily Injury Liability Limits or Combined Single Limit for Liability
Coverage.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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. (MM/DD/YYYY)
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 National Association of
Insurance Commissioners (NAIC).
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SECTION A
Split Limits $10,000 / 20,000
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are
$10,000 each person and $20,000 each accident.
SECTION A
$25,000 / 50,000
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are
$25,000 each person and $50,000 each accident.
SECTION A
$50,000 / 100,000
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are
$50,000 each person and $100,000 each accident.
SECTION A
$100,000 / 300,000
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are
$100,000 each person and $300,000 each accident.
ACORD 61 FL (2011/10) rev. 12-17-2014
Page 2 of 4
SECTION A
$250,000 / 500,000
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are
$250,000 each person and $500,000 each accident.
SECTION A
$500,000 / 1,000,000
Check the box (if applicable): Indicates the limits for uninsured motorist coverage is $500,000
each person $1,000,000 each accident.
SECTION A
Other amount indicator
Check the box (if applicable): Indicates uninsured motorist coverage of an other limit have been
selected.
SECTION A
Other: $
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.)
SECTION A
Other: $
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.
SECTION A
Combined Single Limit
$20,000
Check the box (if applicable): Indicates the limit for the uninsured motorist coverage combined
single limit coverage is $20,000.
SECTION A
$50,000
Check the box (if applicable): Indicates the uninsured motorist coverage combined single limit
coverage is $50,000.
SECTION A
$100,000
Check the box (if applicable): Indicates the limit for the uninsured motorists combined single
limit coverage is $100,000.
SECTION A
$250,000
Check the box (if applicable): Indicates the limit for the uninsured motorists combined single
limit coverage is $250,000.
SECTION A
$300,000
Check the box (if applicable): Indicates the limit for the uninsured motorists combined single
limit coverage is $300,000.
SECTION A
$500,000
Check the box (if applicable): Indicates the limit for the uninsured motorists combined single
limit coverage is $500,000.
SECTION A
$1,000,000
Check the box (if applicable): Indicates the limit for the uninsured motorist coverage combined
single limit coverage is $1,000,000.
SECTION A
Other amount indicator
Check the box (if applicable): Indicates uninsured motorist coverage of an other limit have been
selected.
SECTION A
Other: $
Enter limit: The limit associated with uninsured motorist coverage.
SECTION A
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION A
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SECTION B
I select the following
Uninsured Motorist
Coverage limit(s)
(checkbox)
Check the box (if applicable): Indicates the named insured has selected uninsured motorists
coverage limits listed.
ACORD 61 FL (2011/10) rev. 12-17-2014
Page 3 of 4
SECTION B
Combined Single Limit
(checkbox)
Check the box (if applicable): Indicates the named insured selects uninsured motorists coverage
with a combined single limit.
SECTION B
Combined Single Limit
amount
Enter limit: The uninsured motorists combined single limit per accident limit amount.
SECTION B
Bodily Injury Liability Limits
(checkbox)
Check the box (if applicable): Indicates that Uninsured Motorist Bodily Injury limits have been
selected.
SECTION B
$ each person
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.)
SECTION B
$ each accident
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.
SECTION B
I reject the following
Uninsured Motorist
Coverage limit (s)
(checkbox)
Check the box (if applicable): Indicates uninsured motorists coverage has been rejected by the
named insured.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SECTION C
I hereby elect the
non-stacked form of
Uninsured Motorist
Coverage (checkbox)
Check the box (if applicable): Indicates the uninsured motorists coverage is not stacked.
SECTION C
I hereby elect the stacked
form of Uninsured Motorist
Coverage (checkbox)
Check the box (if applicable): Indicates the uninsured motorists coverage is stacked.
SECTION C
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SECTION C
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)