Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/02/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 61 DE (2006/10)
Delaware Auto Supplement -
Delaware Motorist's Protection Act
- Required Statement To
Policyholders
ACORD 61 DE, Delaware Auto Supplement - Delaware Motorist's
Protection Act - Required Statement To Policyholders, complies with Delaware Regulation
9. The selection of limits or rejection of coverage is valid for all insureds under the policy.
Use this form with ACORD 90 DE, and any commercial auto applications.
IDENTIFICATION SECTION Agency
Enter text: The full name 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.
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES
1 Liability Coverage (Compulsory)
A. Split Limits Liability (1) Bodily
Injury Liability Limits as shown in
Column C (checkbox)
Check the box (if applicable): Indicates the named insured has selected the limits shown.
COVERAGES
Minimum Limits
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Bodily Injury Limit Each Person ($)
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
ACORD 61 DE (2006/10)
1 of 5
Section Name
Field Name
Field and/or Section Description
COVERAGES
Bodily Injury Limits Each Accident
($)
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGES
Property Damage Liability Limits
as Shown in Column C (checkbox)
Check the box (if applicable): Indicates the named insured has selected the limits shown.
COVERAGES
Property Damage Liability
Minimum Limits (checkbox)
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Property Damage Limits ($)
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Combined Single Limit Liability
Column C (checkbox)
Check the box (if applicable): Indicates the named insured has selected the limits shown.
COVERAGES
Combined Single Limit Minimum
Limits
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Combined Single Limit Each
Accident ($)
Enter limit: The vehicle combined single limit liability each accident amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
2 No-Fault Split Limit Additional
Limits as shown in Col. C
Check the box (if applicable): Indicates the named insured has selected the additional
limits shown.
COVERAGES
Minimum Limits
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Personal Injury Protection Limits
Each Person ($)
Enter limit: The additional personal injury protection (APIP) per person limit amount.
COVERAGES
Personal Injury Protection Limits
Each Accident ($)
Enter limit: The additional personal injury protection (APIP) per accident limit amount.
COVERAGES
Combined Single Limit Additional
Limits as shown in Col. C
Check the box (if applicable): Indicates the named insured has selected the additional
limits shown.
COVERAGES
Combined Single Limit Additional
Limits Minimum Limits
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Combined Single Limit Each
Accident ($)
Enter limit: The additional personal injury protection (APIP) per accident limit amount.
COVERAGES
Full Coverage with no Deductible
(checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) has no
deductible that applies.
ACORD 61 DE (2006/10)
2 of 5
Section Name
Field Name
Field and/or Section Description
COVERAGES
Yes (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage
and no deductible has been selected.
COVERAGES
No (checkbox)
Check the box (if applicable): Indicates personal injury protection (PIP) with full coverage
and no deductible has not been selected.
COVERAGES
Cost ($)
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES
Deductible Applicable to Named
Insured only
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured.
COVERAGES
Deductible Applicable to Named
Insured and Member of his or her
Household
Check the box (if applicable): Indicates the personal injury protection (PIP) coverage
applies to the named insured and household members.
COVERAGES
$250 (checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is
$250.
COVERAGES
Cost ($)
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES
$500 (checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is
$500.
COVERAGES
Cost ($)
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES
$1,000 (checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is
$1000.
COVERAGES
Cost ($)
Enter amount: The premium associated with personal injury protection (PIP) coverage.
COVERAGES
Restricted Coverage (checkbox)
Check the box (if applicable): Indicates the personal injury protection (PIP) motorcycle
restricted coverage has been selected.
COVERAGES
$250 (checkbox)
Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP)
deductible amount is $250.
COVERAGES
Cost ($)
Enter amount: The motorcycle personal injury protection (MPIP) premium amount.
COVERAGES
$500 (checkbox)
Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP)
deductible amount is $500.
COVERAGES
Cost ($)
Enter amount: The motorcycle personal injury protection (MPIP) premium amount.
COVERAGES
$1,000 (checkbox)
Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP)
deductible amount is $1,000.
COVERAGES
Cost ($)
Enter amount: The motorcycle personal injury protection (MPIP) premium amount.
COVERAGES
Other (checkbox)
Check the box (if applicable): Indicates motorcycle personal injury protection (MPIP)
deductible amount is other than those listed.
ACORD 61 DE (2006/10)
3 of 5
Section Name
Field Name
Field and/or Section Description
COVERAGES
Other Blank Field ($)
Enter deductible: The motorcycle personal injury protection (MPIP) deductible amount.
COVERAGES
Cost Other ($)
Enter amount: The motorcycle personal injury protection (MPIP) premium amount.
COVERAGES
3 Physical Damage Collision
(checkbox)
Check the box (if applicable): Indicates the named insured requests collision coverage.
COVERAGES
To Reject This Coverage
(checkbox)
Check the box (if applicable): Indicates collision coverage has been rejected in its entirety.
COVERAGES
Deductible ($)
Enter deductible: The collision deductible amount.
COVERAGES
Comprehensive (checkbox)
Check the box (if applicable): Indicates the named insured requests comprehensive
coverage.
COVERAGES
To Reject This Coverage
(checkbox)
Check the box (if applicable): Indicates comprehensive coverage has been rejected in its
entirety.
COVERAGES
Deductible ($)
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES
4 Car Rental Expense Yes
(checkbox)
Check the box (if applicable): Indicates the named insured requests rental reimbursement
coverage.
COVERAGES
No (checkbox)
Check the box (if applicable): Indicates the named insured does not request rental
reimbursement coverage.
COVERAGES
Per Day ($)
Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES
Max ($)
Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES
5 Uninsured/ Underinsured Vehicle
Coverage Split Limit Minimum
Limit (checkbox)
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Bodily Injury and Property Damage
Liability (checkbox)
Check the box (if applicable): Indicates uninsured / underinsured limits equal to bodily
injury and property damage limits have been selected.
COVERAGES
Combined Single Limit Minimum
Limits (checkbox)
Check the box (if applicable): Indicates the named insured has selected the minimum
limits for the coverage.
COVERAGES
Limits Equal to Policy Limit
Check the box (if applicable): Indicates uninsured / underinsured limits equal to combined
single limit has been selected.
COVERAGES
Other Limits as shown in Column
C
Check the box (if applicable): Indicates the named insured has selected the limits shown.
COVERAGES
Each Person ($)
Enter limit: The uninsured / underinsured motorists bodily injury per person limit. The use
of this limit varies by state. On commercial policies, this may contain the combined single
limit per accident amount.
ACORD 61 DE (2006/10)
4 of 5
Section Name
Field Name
Field and/or Section Description
COVERAGES
Each Accident ($)
Enter limit: The uninsured / underinsured motorists bodily injury per accident limit (in some
states this may contain the uninsured / underinsured motorists combined single limit per
accident limit). The use of this limit varies by state.
COVERAGES
Combined Single Limit ($)
Enter limit: The uninsured / underinsured motorists combined single limit per accident
amount. The use of this limit varies by state.
COVERAGES
To Reject This Coverage
(checkbox)
Check the box (if applicable): Indicates uninsured / underinsured coverage has been
rejected in its entirety.
SIGNATURE
Signature of 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.
SIGNATURE
Signature of 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.
SIGNATURE
Agent's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
Signature of Named Insured
Sign here: Accommodates the signature of the applicant or 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 DE (2006/10)
5 of 5