ACORD 61 CA (2008/03)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 09/11/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 61 CA (2008/03)
California Auto Supplement
ACORD 61 CA, California Auto Supplement, complies with California
law and regulations, which require that the insured:
* Must be offered Uninsured Motorists Bodily Injury (UMBI) coverage up to the limits of
Bodily Injury coverage in the policy;
* Can reject UMBI completely, or can reject UMBI with respect to individual drivers
* Can select an UMBI limit(s) which are lower than the policy limits for Bodily Injury, but
not lower than the financial responsibility requirements.
Any of these selection/rejection options must be agreed to in writing by the insured. Use
this form with ACORD 90 CA, and all commercial auto applications, unless the applicant
selects UM BI limits at the policy's BI coverage limit(s).
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 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 Applicant (First Name Insured)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
REJECTION UNINSURED
MOTORISTS BODILY
INJURY COVERAGE
Reject Uninsured Motorists
Coverage
Initial here: The named insured's initials. As used here, indicates the named insured
rejects uninsured motorists bodily injury coverage entirely.
REJECTION UNINSURED
MOTORISTS BODILY
INJURY COVERAGE
Reject only with respect to the
following
Initial here: The named insured's initials. As used here, indicates the named insured
rejects uninsured motorists bodily injury coverage only with respect to the excluded drivers
listed below.
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Section Name
Field Name
Field and/or Section Description
REJECTION UNINSURED
MOTORISTS BODILY
INJURY COVERAGE
Name of Driver(s)
Enter text: The driver's full name. As used here, this is the name of an excluded driver.
REJECTION UNINSURED
MOTORISTS BODILY
INJURY COVERAGE
Name of Driver(s)
Enter text: The driver's full name. As used here, this is the name of an excluded driver.
LOWER LIMIT FOR
UNINSURED MOTORISTS
BODILY INJUY COVERAGE Coverage limit(s) of
Select Uninsured Motorists
Initial here: The named insured's initials. As used here, indicates the named insured
selects uninsured motorists bodily injury coverage with the limit listed.
LOWER LIMIT FOR
UNINSURED MOTORISTS
BODILY INJUY COVERAGE Amount
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.
SIGNATURE
Applicant's Signature
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.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the uninsured motorists bodily injury selection / rejection.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
UNINSURED MOTORISTS
PROPERTY DAMAGE
I select Uninsured Motorists
Property Damage Coverage
Initial here: The named insured's initials. As used here, indicates the named insured
selects uninsured motorists property damage coverage at a limit of $3,500 for each
accident for the vehicles listed below.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Year
Enter year: The model year of the vehicle.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
UNINSURED MOTORISTS
PROPERTY DAMAGE
Model
Enter text: The manufacturer's model name for the vehicle.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Year
Enter year: The model year of the vehicle.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
UNINSURED MOTORISTS
PROPERTY DAMAGE
Model
Enter text: The manufacturer's model name for the vehicle.
ACORD 61 CA (2008/03)
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Section Name
Field Name
Field and/or Section Description
UNINSURED MOTORISTS
PROPERTY DAMAGE
Year
Enter year: The model year of the vehicle.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
UNINSURED MOTORISTS
PROPERTY DAMAGE
Model
Enter text: The manufacturer's model name for the vehicle.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Reject Uninsured Motorists
Property Damage entirely.
Initial here: The named insured's initials. As used here, indicates the named insured
rejects uninsured motorists property damage coverage entirely.
UNINSURED MOTORISTS
PROPERTY DAMAGE
I reject Uninsured Motorists
Property Damage Coverage only
with respect to the following
individuals:
Initial here: The named insured's initials. As used here, indicates the named insured
rejects uninsured motorists property damage coverage only with respect to the individuals
listed below.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Name(s) of excluded driver(s)
Enter text: The driver's full name.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Name(s) of excluded driver(s)
Enter text: The driver's full name.
UNINSURED MOTORISTS
PROPERTY DAMAGE
Name(s) of excluded driver(s)
Enter text: The driver's full name.
SIGNATURE
Signature
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.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the uninsured motorists property damage selection /
rejection.
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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