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ACORD Form 61 PA Pennsylvania Auto
Supp, 1st Party Benefits Cov Instructions

 

 
ACORD 61 PA (2007/08)
Section Name Field Name Field and/or Section Description
ACORD 61 PA, Pennsylvania Auto Supplement - Important Notice, complies with Pennsylvania law and regulations which require that every applicant for auto insurance must:
* Have "no-fault" coverages and options explained
* Be allowed to select among various coverage options shown on ACORD 61 PA
* Have driver improvement course and safety equipment credits explained
The first named insured must sign this form in several places.
Use with ACORD 90 PA and any ACORD Commercial Auto application.
The Pennsylvania Insurance Department no longer requires insurers using this form to file it with the Department before use.
IMPORTANT NOTICE:
1. The benefit options shown in this form are based on the coverage limits provided in the Insurance Services Office (ISO) Private Passenger Auto Exception Pages for Pennsylvania.
TITLE ACORD 61 PA (2007/08) Pennsylvania Auto Supplement -Important Notice 2. For policies written on a semi-annual basis, the Pennsylvania Dept. of Insurance is of the opinion that the annual premium figures that must be shown on page 3 of this form would be twice the semi-annual premium in effect at the time the form is signed.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer's name.
ACORD 61 PA (2007/08)
Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Applicant (First Name Insured) 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).
IDENTIFICATION SECTION Policy Number The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier 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 you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IMPORTANT NOTICE Signature of First Named Insured First Named Insured must sign the form.
IMPORTANT NOTICE Date Date the form was signed. (MM/DD/YYYY)
IMPORTANT NOTICE Effective Date Indicate the effective date of the selected coverage(s). (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Medical Benefit Check the applicable limit. If "Other", identify.
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Work Loss Benefit Check the applicable limit. If "Other", identify.
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Funeral Expense Check the applicable limit. If "Other", identify.
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Accidental Death Benefit Check the applicable limit. If "Other", identify.
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Signature of First Named Insured First Named Insured must sign their selection.
ACORD 61 PA (2007/08)
Section Name Field Name Field and/or Section Description
BASIC FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Date Date the selection was signed. (MM/DD/YYYY)
COMBINATION FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Option Check the desired combination of benefits option. If "Other", identify.
COMBINATION FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Signature of First Named Insured First Named Insured must sign their selection.
COMBINATION FIRST PARTY BENEFITS COVERAGE LIMITS OPTIONS Date Date the selection was signed. (MM/DD/YYYY)
EXTRAORDINARY MEDICAL BENEFITS COVERAGE LIMITS OPTION Check the appropriate box.
EXTRAORDINARY MEDICAL BENEFITS COVERAGE LIMITS OPTION Signature of First Named Insured First Named Insured must sign their selection.
EXTRAORDINARY MEDICAL BENEFITS COVERAGE LIMITS OPTION Date Date the selection was signed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
LIABILITY COVERAGE LIMITS Premium for this coverage would be: Indicate the premium for this coverage.
LIABILITY COVERAGE LIMITS Signature of First Named Insured First Named Insured must sign their selection.
LIABILITY COVERAGE LIMITS Date Date the selection was signed. (MM/DD/YYYY)
ACORD 61 PA (2007/08)
Section Name Field Name Field and/or Section Description
TORT OPTION SELECTION A. Limited Tort Option. The annual premium for basic coverage as required by law under this "Limited Tort" option is $ Indicate the premium for this limited tort option.
TORT OPTION SELECTION A. Full Tort Option. The annual premium for basic coverage as required by law under this "Full Tort" option is $ Indicate the premium for this full tort option.
TORT OPTION SELECTION I wish to choose the limited tort option as described in paragraph A - Signature of Named Insured Named Insured must sign their selection.
TORT OPTION SELECTION Date Date the selection was signed. (MM/DD/YYYY)
TORT OPTION SELECTION I wish to choose the full tort option as described in paragraph B -Signature of Named Insured Named Insured must sign their selection.
TORT OPTION SELECTION Date Date the selection was signed. (MM/DD/YYYY)
COLLISION DEDUCTIBLE OPTION If you wish to carry a collision deductible lower than $500, please indicate your selection below: Check the applicable deductible. If "OTHER", identify.
COLLISION DEDUCTIBLE OPTION Signature of First Named Insured First Named Insured must sign their selection.
COLLISION DEDUCTIBLE OPTION Date Date the selection was signed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
PASSIVE RESTRAINT DISCOUNT Vehicle 1 List the year, make and model of the vehicle.
PASSIVE RESTRAINT DISCOUNT Check boxes Check all that apply.
Section Name Field Name Field and/or Section Description
PASSIVE RESTRAINT DISCOUNT Vehicle 2 List the year, make and model of the vehicle.
PASSIVE RESTRAINT DISCOUNT Check boxes Check all that apply.
PASSIVE RESTRAINT DISCOUNT Vehicle 3 List the year, make and model of the vehicle.
PASSIVE RESTRAINT DISCOUNT Check boxes Check all that apply.
ANTI-THEFT DISCOUNT Vehicle 1 List the year, make and model of the vehicle.
ANTI-THEFT DISCOUNT Check boxes Check all that apply.
ANTI-THEFT DISCOUNT Vehicle 2 List the year, make and model of the vehicle.
ANTI-THEFT DISCOUNT Check boxes Check all that apply.
ANTI-THEFT DISCOUNT Vehicle 3 List the year, make and model of the vehicle.
ANTI-THEFT DISCOUNT Check boxes Check all that apply.
SIGNATURE Applicant's Signature Applicant must sign the form.
SIGNATURE Date Date the form was signed. (MM/DD/YYYY)

ACORD 61 PA (2007/08)