Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 62 PA (2012/10)
Pennsylvania Auto Supplement
ACORD 62 PA, Pennsylvania Auto Supplement, Underinsured
Motorist Coverage Selection / Rejection, provides for selection or rejection of
Underinsured Motorist Coverage.
According to Pennsylvania law, this form must be separate from any other form.
Use ACORD 62 PA with 90 PA, and all commercial auto applications.
The Pennsylvania Insurance Department no longer requires insurers using this form to file
it with the Department before use.
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.
REJECTION OF
UNDERINSURED
MOTORIST PROTECTION
Reject Underinsured Motorist
Protection Signature of First
Named Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured has rejected underinsured motorist coverage for themselves
and all relatives residing in their household.
REJECTION OF
UNDERINSURED
MOTORIST PROTECTION
Date
Enter date: The date the form was signed by the named insured.
SELECTION OF
UNDERINSURED
MOTORIST PROTECTION
Select Underinsured Motorist
Protection ($)
Enter limit: The underinsured motorists combined single limit per accident limit amount.
SELECTION OF
UNDERINSURED
MOTORIST PROTECTION
Select Underinsured Motorist
Protection ($)
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
ACORD 62 PA (2012/10) rev. 09-28-2012
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Section Name
Field Name
Field and/or Section Description
SELECTION OF
UNDERINSURED
MOTORIST PROTECTION
Select Underinsured Motorist
Protection ($)
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.
SELECTION OF
UNDERINSURED
MOTORIST PROTECTION
Select Underinsured Motorist
Protection Signature of First
Named Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured has accepted underinsured motorist coverage.
SELECTION OF
UNDERINSURED
MOTORIST PROTECTION
Date
Enter date: The date the form was signed by the named insured.
RETAIN STACKING OF
UNDERINSURED
MOTORIST COVERAGE
1. Retain stacking. Signature of
First Named Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured wants to retain stacking of their underinsured motorist
coverage.
RETAIN STACKING OF
UNDERINSURED
MOTORIST COVERAGE
Date
Enter date: The date the form was signed by the named insured.
REJECTION OF STACKED
LIMITS FOR
UNDERINSURED
MOTORIST COVERAGE
2. Reject Stacking and choose non-
stacked. Signature of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured has rejected stacking and selects non-stacked underinsured
motorist coverage.
REJECTION OF STACKED
LIMITS FOR
UNDERINSURED
MOTORIST COVERAGE
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 underinsured 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 62 PA (2012/10) rev. 09-28-2012
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