ACORD 64 NY (2008/06)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 64 NY (2008/06)
New York Auto Supplement
ACORD 64 NY, New York Auto Supplement, complies with New York state law, which
requires that Supplementary Uninsured / Underinsured Motorists insurance coverage must
be offered to all policyholders in New York state. Most of the text in this form is from NY
Regulation 35-D, third amendment.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency
Producer's name.
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.
IDENTIFICATION SECTION Named Insured(s)
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).
ELECTION OF SUM
COVERAGE
Split Limits Check Box
$25,000 per person / $50,000 per
accident
Check the desired limits.
ELECTION OF SUM
COVERAGE
Split Limits Check Box
$50,000 per person / $100,000 per
accident
Check the desired limits.
ELECTION OF SUM
COVERAGE
Split Limits Check Box
$100,000 per person / $300,000 per
accident
Check the desired limits.
ELECTION OF SUM
COVERAGE
Split Limits Check Box
$250,000 per person / $500,000 per
accident
Check the desired limits.
ACORD 64 NY (2008/06)
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ELECTION OF SUM
COVERAGE
Split Limits Check Box
$500,000 per person / $1,000,000
per accident
Check the desired limits.
ELECTION OF SUM
COVERAGE
Split Limits Check Box
$ per person / $ per accident
Check the desired limits.
ELECTION OF SUM
COVERAGE
Split Limits $ per person
Enter the desired limit.
ELECTION OF SUM
COVERAGE
Split Limits $ per accident
Enter the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$50,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$100,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$250,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$350,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$500,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$1,000,000 per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit Check Box
$ per person / $ per accident
Check the desired limit.
ELECTION OF SUM
COVERAGE
Combined Single Limit per
accident
Enter the desired limit.
SIGNATURE
Applicant's Signature
Applicant/Named Insured must sign the application.
SIGNATURE
Date
Date the application was completed. (MM/DD/YYYY)
SIGNATURE
Effective Date
Enter the effective date of the Supplementary Uninsured / Underinsured Motorists
coverage. (MM/DD/YYYY)
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