ACORD 61 CT (2010/01)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 61 CT (2010/01)
Connecticut Auto Supplement
ACORD 61 CT, Connecticut Auto Supplement, complies with
Connecticut laws and regulations, which require that insureds:
* Must be informed of the coverage available under Connecticut's UM statutes, including
both standard UM/UIM and UM Conversion coverage.
* Must be permitted to select among various options relating to UM/UIM and UM
Conversion Coverage
* Connecticut law does not provide for stacking of UM/UIM coverage.
The applicant must sign this form, regardless of the coverage selections made.
Use with ACORD 90 CT, and all commercial auto applications.
IDENTIFICATION SECTION
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 Policy #
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.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
IDENTIFICATION SECTION
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
ELECTION OF COVERAGE
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
ACORD 61 CT (2010/01) rev. 01-29-2010
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Section Name
Field Name
Field and/or Section Description
ELECTION OF COVERAGE Double BI Limit (checkbox)
UM With Standard UIM Coverage
Check the box (if applicable): Indicates the named insured has selected uninsured
motorists limits double to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE BI Limit (checkbox)
Check the box (if applicable): Indicates the named insured has selected uninsured
motorists limits equal to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
Enter limit: The uninsured motorists bodily injury per accident limit (in some states this
may contain the uninsured motorists combined single limit per accident limit). The use of
this limit varies by state.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Minimum Limit (checkbox)
Check the box (if applicable): Indicates the named insured has selected the minimum
uninsured motorists limits.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE (checkbox)
UM Conversion Double BI Limit
Check the box (if applicable): Indicates the named insured has selected uninsured
motorists limits double to the bodily injury limits on their policy.
ACORD 61 CT (2010/01) rev. 01-29-2010
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Section Name
Field Name
Field and/or Section Description
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE BI Limit (checkbox)
Check the box (if applicable): Indicates the named insured has selected uninsured
motorists limits equal to the bodily injury limits on their policy.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
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.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
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.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Option (checkbox)
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
ELECTION OF COVERAGE Limit ($)
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.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
ELECTION OF COVERAGE Minimum Limit (checkbox)
Check the box (if applicable): Indicates the named insured has selected the minimum
uninsured motorists limits.
ELECTION OF COVERAGE Total Coverage Premium ($)
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount.
SIGNATURE
Signature of Any Named Insured
Sign here: Accommodates the signature of the applicant or named insured.
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 61 CT (2010/01) rev. 01-29-2010
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