ACORD 61 PA (2014/02) - PENNSYLVANIA AUTO SUPPLEMENT
ACORD 61 PA (2014/02) - PENNSYLVANIA AUTO SUPPLEMENT
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 or 290 PA and any ACORD Commercial Auto application.
Although this form has been filed and approved by the Pennsylvania Insurance Department, the Department requires that insurers using this form
must notify the Department that they are doing so.
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.
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.
Form Page 1
Section Name
Field Name
Description
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
Named Insured(s)
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.
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Page 1 of 9
SIGNATURE
Signature of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
evidences the first named insured's actual knowledge and understanding of the availability of
these benefits and limits as well as the benefits and limits they have selected.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Effective Date
Enter date: The effective date of the selected coverages.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Basic First Party Benefits
Coverage Limits Options
Medical Benefit $ 5000
(checkbox)
Check the box (if applicable): Indicates a $5,000 (Basic) medical benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Medical Benefit $10,000
(checkbox)
Check the box (if applicable): Indicates a $10,000 medical benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Medical Benefit $25,000
(checkbox)
Check the box (if applicable): Indicates a $25,000 medical benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Medical Benefit $50,000
(checkbox)
Check the box (if applicable): Indicates a $50,000 medical benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Medical Benefit $100,000
(checkbox)
Check the box (if applicable): Indicates a $100,000 medical benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Other (checkbox)
Check the box (if applicable): Indicates a medical benefit limit other than those listed.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Amount
Enter limit: The limit amount for first party benefits medical expense coverage.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum None
(checkbox)
Check the box (if applicable): Indicates no work loss benefit limits were selected.
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BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum
$1,000/5,000 (checkbox)
Check the box (if applicable): Indicates $1,000 monthly and $5,000 maximum work loss benefit
limit amounts.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum
$1,000/15,000
Check the box (if applicable): Indicates $1,000 monthly and $15,000 maximum work loss benefit
limit amounts.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum
$1,500/25,000 (checkbox)
Check the box (if applicable): Indicates $1,500 monthly and $25,000 maximum work loss benefit
limit amounts.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum
$2,500/50,000 (checkbox)
Check the box (if applicable): Indicates $2,500 monthly and $50,000 maximum work loss benefit
limit amounts.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum Other
(checkbox)
Check the box (if applicable): Indicates work loss benefit limits other than those listed.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Work Loss Benefit
Monthly/Maximum ($)
Enter limit: The monthly limit amount for first party benefits work loss coverage.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Enter limit: The maximum limit amount for first party benefits work loss benefits coverage.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Funeral Expense Benefit
None (checkbox)
Check the box (if applicable): Indicates no funeral expense benefit limit was selected.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Funeral Expense Benefit
$1,500 (checkbox)
Check the box (if applicable): Indicates a $1,500 funeral expense benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Funeral Expense Benefit
$2,500 (checkbox)
Check the box (if applicable): Indicates a $2,500 funeral expense benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Funeral Expense Benefit
Other (checkbox)
Check the box (if applicable): Indicates a funeral expense benefit limit other than those listed.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Funeral Expense Benefit
Other ($)
Enter limit: The limit amount for first party benefits funeral expense coverage.
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BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
None (checkbox)
Check the box (if applicable): Indicates no accidental death benefit limit was selected.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
$5,000 (checkbox)
Check the box (if applicable): Indicates a $5,000 accidental death benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
$10,000 (checkbox)
Check the box (if applicable): Indicates a $10,000 accidental death benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
$25,000 (checkbox)
Check the box (if applicable): Indicates a $25,000 accidental death benefit limit.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
Other (checkbox)
Check the box (if applicable): Indicates an accidental death benefit limit other than those listed.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Accidental Death Benefit
Other ($)
Enter limit: The limit amount for first party benefits accidental death coverage.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Signature Of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of basic first party benefits coverage limits options.
BASIC FIRST PARTY
BENEFITS COVERAGE
LIMITS OPTIONS
Date
Enter date: The date the form was signed by the named insured.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Benefits Coverage Option 1
(checkbox)
Check the box (if applicable): Indicates combined first party benefit limits of $50,000 total benefit
limit, $2,500 funeral expense benefit limit and $10,000 accidental death benefit limit.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Benefits Coverage Option 2
(checkbox)
Check the box (if applicable): Indicates combined first party benefit limits of $100,000 total
benefit limit, $2,500 funeral expense benefit limit and $10,000 accidental death benefit limit.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Benefits Coverage Option 3
(checkbox)
Check the box (if applicable): Indicates combined first party benefit limits of $177,500 total
benefit limit, $2,500 funeral expense benefit limit and $25,000 accidental death benefit limit.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Benefits Coverage Option 4
Check the box (if applicable): Indicates combined first party benefit limits of $277,500 total
benefit limit, $2,500 funeral expense benefit limit and $25,000 accidental death benefit limit.
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COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Benefits Coverage Option 5
(checkbox)
Check the box (if applicable): Indicates combined first party benefit limits other than those listed.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Total Benefit Limit Other ($)
Enter limit: The combined first party benefits total limit amount.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Funeral Expense Benefit
Other ($)
Enter limit: The combined first party benefits funeral expense limit amount.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Combination First Party
Accidental Death Benefit
Other ($)
Enter limit: The combined first party benefits accidental death limit amount.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Signature of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of combined first party benefits coverage option.
COMBINATION FIRST
PARTY BENEFITS
COVERAGE OPTION
Date
Enter date: The date the form was signed by the named insured.
EXTRAORDINARY MEDICAL Extraordinary Medical
BENEFITS COVERAGE
LIMITS OPTION
Benefits Coverage Limits
Option $100,000 (checkbox)
Check the box (if applicable): Indicates a $100,000 extraordinary medical benefits limit.
EXTRAORDINARY MEDICAL Extraordinary Medical
BENEFITS COVERAGE
LIMITS OPTION
Benefits Coverage Limits
Option $300,000 (checkbox)
Check the box (if applicable): Indicates a $300,000 extraordinary medical benefits limit.
EXTRAORDINARY MEDICAL Extraordinary Medical
BENEFITS COVERAGE
LIMITS OPTION
Benefits Coverage Limits
Option $500,000 (checkbox)
Check the box (if applicable): Indicates a $500,000 extraordinary medical benefits limit.
EXTRAORDINARY MEDICAL
BENEFITS COVERAGE
LIMITS OPTION
Extraordinary Medical
Benefits Coverage Limits
Option $1,000,000
(checkbox)
Check the box (if applicable): Indicates a $1,000,000 extraordinary medical benefits limit.
EXTRAORDINARY MEDICAL Extraordinary Medical
BENEFITS COVERAGE
LIMITS OPTION
Benefits Coverage Limits
Option None (checkbox)
Check the box (if applicable): Indicates no extraordinary medical benefits coverage is included
on the policy.
EXTRAORDINARY MEDICAL
BENEFITS COVERAGE
LIMITS OPTION
Signature Of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of extraordinary medical benefits coverage limits
option.
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EXTRAORDINARY MEDICAL
BENEFITS COVERAGE
LIMITS OPTION
Date
Enter date: The date the form was signed by the named insured.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
LIABILITY COVERAGE
LIMITS
Premium for this coverage
would be:
Enter amount: The vehicle policy, bodily injury premium amount. As used here, the premium
amount for the minimum liability coverage limits per person, per accident for bodily injury, for
property damage or a combined single limit, as required by the Commonwealth of Pennsylvania.
LIABILITY COVERAGE
LIMITS
Signature of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of the minimum liability coverage limits.
LIABILITY COVERAGE
LIMITS
Date
Enter date: The date the form was signed by the named insured.
TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES
ONLY)
Tort Option Limited Tort ($)
Enter amount: The premium amount for the limited tort option. As used here, applicable to
Personal Auto Policies only.
TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES
ONLY)
Tort Option Full Tort ($)
Enter amount: The premium amount for the full tort option. As used here, applicable to Personal
Auto Policies only.
TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES Insured
ONLY)
Signature of First Named
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of the limited tort option as described in paragraph
A. Applicable to Personal Auto Policies only.
TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES
ONLY)
Date
Enter date: The date the form was signed by the named insured. As used here, applicable to
Personal Auto Policies only.
TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES Insured
ONLY)
Signature of First Named
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured's selection of the full tort option as described in paragraph B.
Applicable to Personal Auto Policies only.
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TORT OPTION SELECTION
(APPLICABLE TO
PERSONAL AUTO POLICIES
ONLY)
Date
Enter date: The date the form was signed by the named insured. As used here, applicable to
Personal Auto Policies only.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Passive Seatbelts
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts.
PASSIVE RESTRAINT
DISCOUNT
Driver side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags.
PASSIVE RESTRAINT
DISCOUNT
Passenger side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Passive Seatbelts
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts.
PASSIVE RESTRAINT
DISCOUNT
Driver side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags.
PASSIVE RESTRAINT
DISCOUNT
Passenger side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags.
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PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Passive Seatbelts
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passive seat belts.
PASSIVE RESTRAINT
DISCOUNT
Driver side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with driver side air bags.
PASSIVE RESTRAINT
DISCOUNT
Passenger side airbag
(checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with passenger side air bags.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Alarm (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As
used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet
away for at least three minutes.
PASSIVE RESTRAINT
DISCOUNT
Manually (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you
can manually set that makes the fuel, ignition or starting system inoperative.
PASSIVE RESTRAINT
DISCOUNT
Automatically (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that
automatically makes the fuel, ignition or starting system inoperative when the ignition is turned
off.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Alarm (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As
used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet
away for at least three minutes.
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PASSIVE RESTRAINT
DISCOUNT
Manually (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you
can manually set that makes the fuel, ignition or starting system inoperative.
PASSIVE RESTRAINT
DISCOUNT
Automatically (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that
automatically makes the fuel, ignition or starting system inoperative when the ignition is turned
off.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Year
Enter year: The model year of the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Vehicle Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
PASSIVE RESTRAINT
DISCOUNT
Vehicle Model
Enter text: The manufacturer's model name for the vehicle.
PASSIVE RESTRAINT
DISCOUNT
Alarm (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with anti-theft alarm system. As
used here, indicates the vehicle is equipped with an alarm that can be heard at least 300 feet
away for at least three minutes.
PASSIVE RESTRAINT
DISCOUNT
Manually (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that you
can manually set that makes the fuel, ignition or starting system inoperative.
PASSIVE RESTRAINT
DISCOUNT
Automatically (checkbox)
Check the box (if applicable): Indicates the vehicle is equipped with an anti-theft device that
automatically makes the fuel, ignition or starting system inoperative when the ignition is turned
off.
PASSIVE RESTRAINT
DISCOUNT
Signature of First Named
Insured
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the first named insured understands that the coverage selection and limit choices
indicated here will apply to all future policy renewals, continuations and changes unless they
notify you otherwise in writing.
PASSIVE RESTRAINT
DISCOUNT
Date
Enter date: The date the form was signed by the named insured.
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