ACORD 61 SC (2007/08)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 09/18/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 61 SC (2007/08)
South Carolina Auto Supplement
ACORD 61 SC, South Carolina Auto Supplement, is used to comply
with South Carolina requirements that UM and optional UIM coverages must be explained
to every applicant for auto insurance.
The text of this form is prescribed by the Insurance Commissioner.
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 Applicant (First Name Insured)
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.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/50/25 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 1 vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/50/25 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 2 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/50/25 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 3-4 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/50/25 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 5-9 vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/50/25 10 - 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 10 - 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
25/20/25 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/20/25 for > 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 1 vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 2 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 3 - 4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 3 - 4 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 5 - 9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 5 - 9 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 10 - 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 10 - 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
50/100/50 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for < 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 1 vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 2 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 3-4 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 5-9 vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 10-30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
100/300/50 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for < 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 1 vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 2 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 3-4 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 5-9 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 10-30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
250/500/50 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for < 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 1
vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 2
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 3-4
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 5-9
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 10-30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for > 30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 1
vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 2
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 3-4
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 5-9
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 10-30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
75,000 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for > 30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 1
vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 2
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 3-4
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 5-9
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 10-30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
150,000 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for > 30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 1
vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 2
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 3 - 4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 3-4
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 5-9
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 10-30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
350,000 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for > 30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 1
vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 2
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 3-4
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 5-9
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 10-30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
550,000 > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for > 30
vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 1
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 1 vehicle.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 2
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 2 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 3-4
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 3-4 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 5-9
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 5-9 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other 10-30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 10-30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Other > 30
Enter amount: The uninsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for > 30 vehicles.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Do you wish to purchase
additional uninsured motorist
coverage? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you wish to
purchase additional uninsured motorists coverage?.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
No
Check the box (if applicable): Indicates a No response to the question, Do you wish to
purchase additional uninsured motorists coverage?.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
If No, you must sign here:
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured selects not to purchase additional uninsured motorists
coverage.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
I Select Split Limits
Check the box (if applicable): Indicates the named insured selects uninsured motorists
coverage with split limits.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Split Limit Amount
Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit
varies by state. (in some states this may contain the combined single limit per accident
limit amount.)
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Split Limit 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.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Split Limit Amount
Enter limit: The uninsured motorists property damage per accident amount. The use of
this limit varies by state.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
I Select Single Limits
Check the box (if applicable): Indicates the named insured selects uninsured motorists
coverage with a combined single limit.
OFFER OF
ADDITIONALUNINSURED
MOTORIST COVERAGE
Single Limit Amount
Enter limit: The uninsured motorists combined single limit per accident limit amount.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/50/25 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 1 vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/50/25 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 2 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/50/25 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 3-4 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/50/25 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 5-9 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/50/25 10 - 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/50/25 for 10 - 30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
25/20/25 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 25/20/25 for > 30 vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 1 vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 2 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 3 - 4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 3 - 4 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 5 - 9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 5 - 9 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 10 - 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for 10 - 30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
50/100/50 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 50/100/50 for < 30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 1 vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 2 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 3-4 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 5-9 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for 10-30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
100/300/50 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 100/300/50 for < 30 vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 1 vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 2 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 3-4 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 5-9 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for 10-30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
250/500/50 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits of 250/500/50 for < 30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 1
vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 2
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 3-4
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 5-9
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for 10-30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for split limits other than those listed for > 30
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 1
vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 2
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 3-4
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 5-9
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for 10-30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
75,000 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 75,000 for > 30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 1
vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 2
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 3-4
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 5-9
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for 10-30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
150,000 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 150,000 for > 30
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 1
vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 2
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 3 - 4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 3-4
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 5-9
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for 10-30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
350,000 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 350,000 for > 30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 1
vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 2
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 3-4
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 5-9
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for 10-30
vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
550,000 > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit of 550,000 for > 30
vehicles.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 1
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 1 vehicle.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 2
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 2 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 3-4
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 3-4 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 5-9
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 5-9 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other 10-30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for 10-30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Other > 30
Enter amount: The underinsured motorists bodily injury or combined single limit premium
amount. As used here, this is the premium for a combined single limit other than those
listed for > 30 vehicles.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Do you wish to purchase optional
uninsured motorist coverage? Yes
Check the box (if applicable): Indicates a Yes response to the question, Do you wish to
purchase optional underinsured motorists coverage?.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
No
Check the box (if applicable): Indicates a No response to the question, Do you wish to
purchase optional underinsured motorists coverage?.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
If No, you must sign here:
Sign here: Accommodates the signature of the applicant or named insured. As used here,
indicates the named insured selects not to purchase optional underinsured motorists
coverage.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
I Select Split Limits
Check the box (if applicable): Indicates the named insured selects underinsured motorists
coverage with split limits.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Split Limit Amount
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit
varies by state. In some states this may contain the combined single limit each accident
amount
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Split Limit Amount
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this
may contain the underinsured motorists combined single per accident limit). The use of
this limit varies by state.
ACORD 61 SC (2007/08)
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Section Name
Field Name
Field and/or Section Description
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Split Limit Amount
Enter limit: The underinsured motorists property damage per accident amount. The use
of this limit varies by state.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
I Select Single Limits
Check the box (if applicable): Indicates the named insured selects underinsured motorists
coverage with a combined single limit.
OFFER OF OPTIONAL
UNDERINSURED
MOTORIST COVERAGE
Single Limit Amount
Enter limit: The underinsured motorists combined single limit per accident limit amount.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
SIGNATURE
Type or Print Your Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE
Your Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Your Address
Enter text: The named insured's mailing address line one.
SIGNATURE
Your Address
Enter text: The named insured's mailing address city name.
SIGNATURE
Enter code: The named insured's mailing address state or province code.
SIGNATURE
Zip Code
Enter code: The named insured's mailing address postal code.
SIGNATURE
Today's 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.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 61 SC (2007/08)
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