ACORD 64 GA (2009/01)

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 08/14/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 64 GA (2009/01)
Georgia Auto Supplement, Georgia
Auto Disclosure Form, Notice to
Policyholders, Uninsured Motorist
Coverage Selection
ACORD 64 GA, Georgia Auto Supplement, Georgia Auto Disclosure
Form, Notice to Policyholders, Uninsured Motorist Coverage Selection, is used to comply
with GA Regulation Bulletin 08-372, which requires that personal auto policyholders must
be notified that their insurance coverage will include revised Uninsured Motorist coverage,
also known as New (Added On) UM, unless the coverage is rejected in writing.
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 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.
NOTICE TO
POLICYHOLDERS,
UNINSURED MOTORIST
SELECTION
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
NOTICE TO
POLICYHOLDERS,
UNINSURED MOTORIST
SELECTION
Date
Enter date: The date the form was signed by the named insured.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 64 GA (2009/01)
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