ACORD 62 NJ (2006/10)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 11/13/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 62 NJ (2006/10)
New Jersey Auto Supplement
Basic Policy Coverage Selection
Form
ACORD 62 NJ, New Jersey Auto Supplement Basic Policy Coverage
Selection Form, is prescribed by the New Jersey Division of Insurance. It provides for
selection of coverages under the basic insurance policy, and refers to ACORD 61NJ,
Auto Insurance Buyers Guide. It should be used with all applications for the Basic policy.
IDENTIFICATION SECTION Producer
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Applicant/Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Company
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 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.
BODILY INJURY LIABILITY Injury Liability Limit
Yes, I Choose the $10,000 Bodily
Check the box (if applicable): Indicates the named insured has selected bodily injury
coverage with a $10,000 limit.
BODILY INJURY LIABILITY Injury Liability Coverage
No, I do not choose to have Bodily
Check the box (if applicable): Indicates the named insured has rejected bodily injury
coverage.
PERSONAL INJURY
PROTECTION
$250
Check the box (if applicable): Indicates the named insured has selected a PIP Medical
Expense Deductible of $250.
ACORD 62 NJ (2006/10)
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Section Name
Field Name
Field and/or Section Description
PERSONAL INJURY
PROTECTION
$500
Check the box (if applicable): Indicates the named insured has selected a PIP Medical
Expense Deductible of $500.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$1,000
Check the box (if applicable): Indicates the named insured has selected a PIP Medical
Expense Deductible of $1,000.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$2,000
Check the box (if applicable): Indicates the named insured has selected a PIP Medical
Expense Deductible of $2,000.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$2,500
Check the box (if applicable): Indicates the named insured has selected a PIP Medical
Expense Deductible of $2,500.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
Percent (%)
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
COLLISION COVERAGE
No, I choose not to be covered for
collision damage
Check the box (if applicable): Indicates the named insured has rejected collision
coverage.
COLLISION COVERAGE
Yes, I choose to be covered for
collision damage with the basic
$750 deductible
Check the box (if applicable): Indicates the named insured has selected a $750 deductible
for collision coverage.
COLLISION COVERAGE
Yes, I choose to be covered for
collision damage with the
deductible checked below.
Check the box (if applicable): Indicates the vehicle has collision coverage.
COLLISION COVERAGE
$1,000
Check the box (if applicable): Indicates the deductible for collision coverage is $1000.
COLLISION COVERAGE
$1,500
Check the box (if applicable): Indicates the named insured has selected a $1,500
deductible for collision coverage.
ACORD 62 NJ (2006/10)
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Section Name
Field Name
Field and/or Section Description
COLLISION COVERAGE
$2,000
Check the box (if applicable): Indicates the named insured has selected a $2,000
deductible for collision coverage.
COLLISION COVERAGE
$100
Check the box (if applicable): Indicates the deductible for collision coverage is $100.
COLLISION COVERAGE
$150
Check the box (if applicable): Indicates the named insured has selected a $150 deductible
for collision coverage.
COLLISION COVERAGE
$200
Check the box (if applicable): Indicates the deductible for collision coverage is $200.
COLLISION COVERAGE
$250
Check the box (if applicable): Indicates the deductible for collision coverage is $250.
COLLISION COVERAGE
$500
Check the box (if applicable): Indicates the deductible for collision coverage is $500.
COMPREHENSIVE
COVERAGE
No, I choose not to be covered for
comprehensive damage
Check the box (if applicable): Indicates comprehensive coverage has been rejected in its
entirety.
COMPREHENSIVE
COVERAGE
Yes, I choose to be covered for
comprehensive damage with the
basic $750 deductible
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$750.
COMPREHENSIVE
COVERAGE
Yes, I choose to be covered for
comprehensive damage with the
deductible checked below.
Check the box (if applicable): Indicates the vehicle has comprehensive coverage.
COMPREHENSIVE
COVERAGE
$1,000
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$1000.
COMPREHENSIVE
COVERAGE
$1,500
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$1,500.
COMPREHENSIVE
COVERAGE
$2,000
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$2,000.
COMPREHENSIVE
COVERAGE
$100
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$100.
COMPREHENSIVE
COVERAGE
$150
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$150.
COMPREHENSIVE
COVERAGE
$200
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$200.
COMPREHENSIVE
COVERAGE
$250
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$250.
COMPREHENSIVE
COVERAGE
$500
Check the box (if applicable): Indicates the deductible for comprehensive coverage is
$500.
STATEMENT OF INSURED
OR APPLICANT
NEW POLICY
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
STATEMENT OF INSURED
OR APPLICANT
Mid-Term Change
Check the box (if applicable): Indicates this form is for a mid-term change request.
ACORD 62 NJ (2006/10)
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Section Name
Field Name
Field and/or Section Description
STATEMENT OF INSURED
OR APPLICANT
Renewal Change
Check the box (if applicable): Indicates this form is for a renewal change request.
STATEMENT OF INSURED Signature of Named Insured or
OR APPLICANT
Applicant
Sign here: Accommodates the signature of the applicant or named insured.
STATEMENT OF INSURED
OR APPLICANT
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).
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