ACORD Form 64 GA Georgia Auto
Supplement Instructions

 

Section Name	Field Name	Field and/or Section Description
TITLE ACORD 64 GA (2009/01)	Georgia Auto Supplement, Georgia Auto Disclosure Form, Notice to Policyholders, Uninsured Motorist Coverage Selection	Use 64 GA, Georgia Auto Supplement, Georgia Auto Disclosure Form, Notice to Policyholders, Uninsured Motorist Coverage Selection, to comply with GA Regulation Bulletin 08-372, which requires that personal auto policyholders must be notified that their insurance coverage will include revised Uninsured Motorist coverage, also known as New (Added On) UM, unless the coverage is rejected in writing.
IDENTIFICATION SECTION	Agency Customer ID	Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION	Agency	Producer's name.
		The number assigned by the insurance company for the policy. In general, policy numbers
IDENTIFICATION SECTION	Policy Number	will not appear on new business applications since they are not known at that point in time.
		Enter the effective date of the Uninsured / Underinsured Motorists coverage rejection.
IDENTIFICATION SECTION	Effective Date	(MM/DD/YYYY)
IDENTIFICATION SECTION	Named Insured(s)	The named insured(s) as it/they appear on the policy declarations page.
		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
IDENTIFICATION SECTION	Carrier	you wish to have the policy issued.
IDENTIFICATION SECTION	NAIC Code	The identification code assigned to the company by the NAIC.
NOTICE TO
POLICYHOLDERS,
UNINSURED MOTORIST
SELECTION	Insured's Signature	Named Insured must sign the application.
NOTICE TO
POLICYHOLDERS,
UNINSURED MOTORIST
SELECTION	Date	Date the application was completed. (MM/DD/YYYY)
IDENTIFICATION SECTION	Agency Customer ID	Customer's identification number assigned by the agency or brokerage.

ACORD 64 GA (2009/01) 1 of 1