ACORD 64 NJ (2010/03) - NJ AUTO SUPPLEMENT STANDARD COVERAGE

ACORD 64 NJ (2010/03) - NJ AUTO SUPPLEMENT STANDARD COVERAGE
ACORD 64 NJ, New Jersey Auto Supplement, Standard Policy Coverage Selection Form, complies with New Jersey laws and regulations which
require that every applicant for auto insurance be given a copy of this supplement, which explains various coverage choices available under the
Standard insurance policy. Specific premium and rate information, as well as differences in premium between various coverages, must be filled in
and provided to the applicant. The applicant must make coverage choices on this form, and must sign it. This form also refers to ACORD 61 NJ,
the Auto Insurance Buyers Guide, prescribed by the New Jersey Insurance Division.
Use with all applications for auto insurance.
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
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
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
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 National Association of
Insurance Commissioners (NAIC).
BODILY INJURY LIABILITY
Choose the Bodily Injury
Liability Limits that you
want: $15000 (checkbox)
Check the box (if applicable): Indicates bodily injury limits of $15,000 have been selected.
BODILY INJURY LIABILITY
$20000 (checkbox)
Check the box (if applicable): Indicates bodily injury limits of $20,000 have been selected.
BODILY INJURY LIABILITY
$25000 (checkbox)
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are
$25,000 each person and $50,000 each accident.
BODILY INJURY LIABILITY
$50000 (checkbox)
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are
$50,000 each person and $100,000 each accident.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 1 of 7
BODILY INJURY LIABILITY
Other Limit Checkbox
Check the box (if applicable): Indicates a bodily injury limit of another amount have been
selected..
BODILY INJURY LIABILITY
Other Limit ($)
Enter limit: The limit associated with bodily injury coverage.
PROPERTY DAMAGE
LIABILITY
Property Damage Liability
$5000 (checkbox)
Check the box (if applicable): Indicates property damage limit of $5,000.
PROPERTY DAMAGE
LIABILITY
$10000 (checkbox)
Check the box (if applicable): Indicates property damage limit of $10,000.
PROPERTY DAMAGE
LIABILITY
$25000 (checkbox)
Check the box (if applicable): Indicates the limit for the property damage liability coverage is
$25,000.
PROPERTY DAMAGE
LIABILITY
$50000 (checkbox)
Check the box (if applicable): Indicates the limit for the property damage liability coverage is
$50,000.
PROPERTY DAMAGE
LIABILITY
Other Limit Checkbox
Check the box (if applicable): Indicates a property damage limit of another amount
PROPERTY DAMAGE
LIABILITY
Other Limit ($)
Enter limit: The limit associated with property damage coverage.
PERSONAL INJURY
PROTECTION
Personal Injury Protection I
choose the standard PIP
Medical Expense Limit of
$250,000. (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage and no
deductible has been selected.
PERSONAL INJURY
PROTECTION
I choose one of the lower
PIP Medical Expense Limits
below. (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage and no
deductible has not been selected.
PERSONAL INJURY
PROTECTION
$150000 (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with $150,000 has been
selected.
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$75000 (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with $75,000 has been
selected.
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 2 of 7
PERSONAL INJURY
PROTECTION
$50000 (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with $50,000 has been
selected
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$15000 (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with $15,000 has been
selected
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$250 deductible, minimum
required by law. (checkbox)
Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense
Deductible of $250.
PERSONAL INJURY
PROTECTION
$500 deductible (checkbox)
Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense
Deductible of $500.
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$1,000 deductible
(checkbox)
Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense
Deductible of $1,000.
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$2,000 deductible
(checkbox)
Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense
Deductible of $2,000.
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
$2,500 deductible
(checkbox)
Check the box (if applicable): Indicates the named insured has selected a PIP Medical Expense
Deductible of $2,500.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 3 of 7
PERSONAL INJURY
PROTECTION
for a _______%
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % reduction in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
I choose my health insurer
for PIP option. (checkbox)
Check the box (if applicable): Indicates that health insurer was selected for the PIP option.
PERSONAL INJURY
PROTECTION
1 Name of Health Insurer #
Enter text: The healthcare 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.
PERSONAL INJURY
PROTECTION
1 Policy/Group/Certificate #
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.
PERSONAL INJURY
PROTECTION
2 Name of Health Insurer #
Enter text: The healthcare 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.
PERSONAL INJURY
PROTECTION
2 Policy/Group/Certificate #
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.
Form Page 2
Section Name
Field Name
Description
PERSONAL INJURY
PROTECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
PERSONAL INJURY
PROTECTION
You may choose not to have
the Extra PIP Package
benefits for a ____ %
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
to _____ % savings in the
PIP premium.
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
PERSONAL INJURY
PROTECTION
I choose PIP Medical
Expense Only. (checkbox)
Check the box (if applicable): Indicates that PIP Medical Expense only coverage was chosen.
UNINSURED/UNDERINSUREDMotorist coverage (up to
MOTORIST COVERAGE
Uninsured/Underinsured
Bodily Injury Limit) $20000
(checkbox)
Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $20,000
have been selected.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 4 of 7
UNINSURED/UNDERINSURED
MOTORIST COVERAGE
$25000 (checkbox)
Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $25,000
have been selected.
UNINSURED/UNDERINSURED
MOTORIST COVERAGE
$50000 (checkbox)
Check the box (if applicable): Indicates uninsured underinsured motorist coverage of $50,000
have been selected.
UNINSURED/UNDERINSURED
MOTORIST COVERAGE
Other Limit (checkbox)
Check the box (if applicable): Indicates uninsured underinsured motorist coverage of an other
limit have been selected.
UNINSURED/UNDERINSURED
MOTORIST COVERAGE
Other Limit ($)
Enter limit: The limit associated with uninsured underinsured motorist coverage.
UNINSURED/UNDERINSUREDMotorist coverage (up to
MOTORIST COVERAGE
Uninsured/Underinsured
Property Damage Limit)
Other Limit (checkbox)
Check the box (if applicable): Indicates uninsured underinsured motorist coverage of an other
limit have been selected.
UNINSURED/UNDERINSURED
MOTORIST COVERAGE
Other Limit ($)
Enter limit: The limit associated with uninsured underinsured motorist coverage.
COLLISION COVERAGE
No, I choose not to be
covered for collision
damage. (checkbox)
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.
(checkbox)
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. (checkbox)
Check the box (if applicable): Indicates the collision deductible chosen is either $1,000, $1,500
or $2,000.
COLLISION COVERAGE
Collision Coverage $1000
(checkbox)
Check the box (if applicable): Indicates the deductible for collision coverage is $1000.
COLLISION COVERAGE
$500 (checkbox)
Check the box (if applicable): Indicates the named insured has selected a $1,500 deductible for
collision coverage.
COLLISION COVERAGE
$2000 (checkbox)
Check the box (if applicable): Indicates the named insured has selected a $2,000 deductible for
collision coverage.
COLLISION COVERAGE
Yes I choose to be covered
for collision damage with
the deductible checked
below. (checkbox)
Check the box (if applicable): Indicates the collision deductible chosen is in the either $100,
$150, $200, $200,$ 250 or$ 500.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 5 of 7
COLLISION COVERAGE
Collision Coverage $100
(checkbox)
Check the box (if applicable): Indicates the deductible for collision coverage is $100.
COLLISION COVERAGE
$150 (checkbox)
Check the box (if applicable): Indicates the named insured has selected a $150 deductible for
collision coverage.
COLLISION COVERAGE
$200 (checkbox)
Check the box (if applicable): Indicates the deductible for collision coverage is $200.
COLLISION COVERAGE
$250 (checkbox)
Check the box (if applicable): Indicates the deductible for collision coverage is $250.
COLLISION COVERAGE
$500 (checkbox)
Check the box (if applicable): Indicates the deductible for collision coverage is $500.
COMPREHENSIVE
COVERAGE
Comprehensive Coverage
No, I choose not to be
covered for comprehensive
damage. (checkbox)
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. (checkbox)
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. (checkbox)
Check the box (if applicable): Indicates the comprehensive deductible chosen is either $1,000,
$1,500 or $2,000.
COMPREHENSIVE
COVERAGE
$1000 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $1000.
COMPREHENSIVE
COVERAGE
$1500 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $1,500.
COMPREHENSIVE
COVERAGE
$2000 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $2,000.
COMPREHENSIVE
COVERAGE
Yes, I choose to be covered
for comprehensive damage
with the deductible checked
below.
Check the box (if applicable): Indicates the comprehensive deductible chosen is in the either
$100, $150, $200, $200,$ 250 or$ 500.
COMPREHENSIVE
COVERAGE
$100 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $100.
COMPREHENSIVE
COVERAGE
$150 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $150.
COMPREHENSIVE
COVERAGE
$200 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $200.
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 6 of 7
COMPREHENSIVE
COVERAGE
$250 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $250.
COMPREHENSIVE
COVERAGE
$500 (checkbox)
Check the box (if applicable): Indicates the deductible for comprehensive coverage is $500.
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).
LAWSUIT OPTIONS
Lawsuit Options I want the
Limitation on Lawsuit
Option. (checkbox)
Check the box (if applicable): Indicates the bodily injury lawsuit limitation option has been
selected.
LAWSUIT OPTIONS
I want the No Limitation on
Lawsuit Option. (checkbox)
Check the box (if applicable): Indicates the bodily injury lawsuit limitation option has not been
selected.
LAWSUIT OPTIONS
My bodily injury liability
premium will be ___ %
Enter percentage: The minimum percentage the premium will be reduced based on the
deductible selected.
LAWSUIT OPTIONS
to ____ %
Enter percentage: The maximum percentage the premium will be reduced based on the
deductible selected.
LAWSUIT OPTIONS
Per vehicle, my bodily injury
liability premium at current
rates will be $ ____
Enter amount: The minimum the bodily liability premium will increase based on the deductible
selected.
LAWSUIT OPTIONS
to $_______
Enter amount: The maximum the bodily liability premium will increase based on the deductible
selected.
LAWSUIT OPTIONS
higher on each ____ renewal
Enter text: The description of how often a policy renews e.g. annually or semi-annually.
STATEMENT OF INSURED
OR APPLICANT
Statement of Insured or
Applicant New Policy
(checkbox)
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
(checkbox)
Check the box (if applicable): Indicates this form is for a mid-term change request.
STATEMENT OF INSURED
OR APPLICANT
Renewal Change (checkbox)
Check the box (if applicable): Indicates this form is for a renewal change request.
SIGNATURE
Signature of named insured
or applicant:
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
ACORD 64 NJ (2010/03) FIG rev. 12-16-2014
Page 7 of 7