ACORD 62 FL (2013/12) - Florida Commercial Auto Supplement - PIP Options

ACORD 62 FL (2013/12) - Florida Commercial Auto Supplement - PIP Options
ACORD 62 FL, Florida Commercial Auto Supplement, Personal Injury Protection (No-Fault Coverage) Options, complies with Florida law, 627.739
which requires that for personal injury protection insurance, the named insured may elect a deductible and exclude coverage for loss of gross
income and loss of earning capacity (lost wages or work loss). These elections may apply to the named insured alone, or to the named insured
and all dependent relatives residing in the same household.
Use with ACORD 137 FL, and any commercial auto application where the named insured is designated as an individual in the Declaration of the
auto policy.
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
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
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
OPTION I. DEDUCTIBLE
I do not want a deductible to
apply to my policy's
Personal Injury Protection
coverage.
Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible
that applies.
OPTION I. DEDUCTIBLE
I hereby elect the deductible
indicated below.
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies.
As used here, indicate to whom the deductible applies by checking the applicable box.
OPTION I. DEDUCTIBLE
Named Insured - $250
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured only. As used here, the deductible amount is $250.
OPTION I. DEDUCTIBLE
Named Insured and All
Dependent Resident
Relatives - $250
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured and resident relatives. As used here, the deductible amount is $250.
ACORD 62 FL (2013/12) rev. 04-09-2014
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OPTION I. DEDUCTIBLE
Named Insured - $500
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured only. As used here, the deductible amount is $500.
OPTION I. DEDUCTIBLE
Named Insured and All
Dependent Resident
Relatives - $500
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured and resident relatives. As used here, the deductible amount is $500.
OPTION I. DEDUCTIBLE
Named Insured - $1,000
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured only. As used here, the deductible amount is $1000.
OPTION I. DEDUCTIBLE
Named Insured and All
Dependent Resident
Relatives - $1,000
Check the box (if applicable): Indicates the personal injury protection (PIP) deductible applies to
the named insured and resident relatives. As used here, the deductible amount is $1000.
OPTION II. EXCLUSION OF
WORK LOSS BENEFITS
Exclude Work Loss benefits
for the Named Insured and
All Dependent Resident
Relatives.
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured and dependent resident relatives.
OPTION II. EXCLUSION OF
WORK LOSS BENEFITS
Exclude Work Loss benefits
for the Named Insured Only
Check the box (if applicable): Indicates the personal injury protection (PIP) work loss exclusion
applies to the named insured only.
Form Page 2
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).
OPTION III. EXTENDED
PERSONAL INJURY
PROTECTION BENEFITS
I choose OPTION A as
outlined above (checkbox)
Check the box (if applicable): Indicates the extended personal injury protection (EPIP) includes
work loss. As used here, indicates extended personal injury protection benefits are for the
named insured and all dependent resident relatives which includes 80% of work loss.
OPTION III. EXTENDED
PERSONAL INJURY
PROTECTION BENEFITS
I choose OPTION B as
outlined above (checkbox)
Check the box (if applicable): Indicates the extended personal injury protection (EPIP) excludes
work loss. As used here, indicates extended personal injury protection benefits are for the
named insured and all dependent resident relatives which includes no work loss.
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
$10,000 Additional Limit
(checkbox)
Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit
is $10,000
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
$25,000 Additional Limit
(checkbox)
Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit
is $25,000
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
$40,000 Additional Limit
(checkbox)
Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit
is $40,000
ACORD 62 FL (2013/12) rev. 04-09-2014
Page 2 of 3
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
$90,000 Additional Limit
(checkbox)
Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit
is $90,000
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
Other Additional Limit
(checkbox)
Check the box (if applicable): Indicates that the additional personal injury protection (APIP) limit
is other than those listed.
OPTION IV. ADDITIONAL
PERSONAL INJURY
PROTECTION BENEFITS
Other Additional Limit
amount
Enter limit: The additional personal injury protection (APIP) limit amount.
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.
ACORD 62 FL (2013/12) rev. 04-09-2014
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