Universal wording updates to improve clarity and intent were made to all FIG text for this form on 07/24/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 64 CO (2009/01)
Colorado Auto Supplement,
Colorado Offer of Medical
Payments Coverage
ACORD 64 CO, Colorado Auto Supplement, Colorado Offer of
Medical Payments Coverage, is used to comply with Colorado statutes and regulations
that require notification to existing personal auto policyholders that every policy must
include Medical Payments coverage with a limit of at least $5,000, and that higher limits
are available. The insured can reject coverage in writing. Motorcycles, motor scooters,
motor bikes and similar vehicles are exempt from these requirements.
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.
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 NAIC.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Initials: I select Standard Medical
Payments Coverage limits of
$5,000 per person.
Initial here: The named insured's initials. As used here, indicates the insured has selected
Standard Medical Payments Coverage limits of $5,000 per person.
OFFER OF MEDICAL
PAYMENTS COVERAGE
The premium for this coverage is:
Enter amount: The medical payments premium amount.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage limit 1
Enter limit: The excess medical payment per person limit amount. As used here, this
information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage premium 1
Enter amount: The premium amount associated with excess medical payments coverage.
As used here, this information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage limit 2
Enter limit: The excess medical payment per person limit amount. As used here, this
information is to indicate a limit available and its associated premium.
ACORD 64 CO (2009/01)
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Section Name
Field Name
Field and/or Section Description
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage premium 2
Enter amount: The premium amount associated with excess medical payments coverage.
As used here, this information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage limit 3
Enter limit: The excess medical payment per person limit amount. As used here, this
information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage premium 3
Enter amount: The premium amount associated with excess medical payments coverage.
As used here, this information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage limit 4
Enter limit: The excess medical payment per person limit amount. As used here, this
information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Excess Medical Payments
Coverage premium 4
Enter amount: The premium amount associated with excess medical payments coverage.
As used here, this information is to indicate a limit available and its associated premium.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Initials: I select Excess Medical
Payments Coverage limits of per
person.
Initial here: The named insured's initials. As used here, indicates the insured has selected
Excess Medical Payments Coverage with the limit listed.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Medical Payments Coverage Limit
Enter limit: The excess medical payment per person limit amount. As used here, this is the
limit that has been selected by the insured.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Initials: I reject Medical Payments
Coverage in its entirety.
Initial here: The named insured's initials. As used here, indicates the insured has rejected
Medical Payments Coverage in its entirety.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Named Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
OFFER OF MEDICAL
PAYMENTS COVERAGE
Date
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 64 CO (2009/01)
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