Important Information Regarding Personal Injury Protection Coverage Deductibles

Important Information Regarding Personal Injury Protection Coverage Deductibles

I understand that Personal Injury Protection Coverage for covered expenses incurred because of bodily injury to me, a resident relative, or to any other household resident who is economically dependent on me, shall be subject to a deductible. The deductible will be applied to reduce the total of all sums that the Company is obligated to pay for Personal Injury Protection Coverage as a result of an accident.

The Personal Injury Protection Coverage deductibles available to me are $0, $250, $500, $1,000, $2,000 and $5,000 deductibles. Personal Injury Protection Coverage options available to me are coverage for only me or coverage for me along with resident relatives and household members who are economically dependent on me. By my signature below, I acknowledge receipt of a copy of this notice regarding Personal Injury Protection Coverage deductibles.

I understand and agree that this election shall be binding on all persons subject to the deducible and that this election shall also apply to any renewal, reinstatement, substitute, amended, altered, modified, or replacement policy with this Company or any affiliated Company, unless a named insured submits a written request to change the deductible and pays any additional premium that may apply.

I understand that in order for my deductible election to be valid, I must sign both this form and the enclosed form entitled “Election of Personal Injury Protection Coverage Deductibles.” If I do not return both forms, I understand that I will receive and be required to pay for Personal Injury Protection Coverage with no deductible.

APPLICANT'S SIGNATUREPOLICY/BINDER NUMBER

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(If under 18, Guardian's Signature is required)

DATE:

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AIIC DE PIPINFO (10/04)

Election of Personal Injury Protection Coverage Deducible

I understand that Personal Injury Protection Coverage for covered expenses incurred because of bodily injury to me, a resident relative, or to any other household resident who is economically dependent on me, shall be subject to the deductible I have elected. The deductible elected will be applied to reduce the total of all sums, which the Company is obligated to pay for Personal Injury Protection Coverage as a result of an accident.

I understand and agree that this election shall be binding on all persons subject to the deductible and that this election shall also apply to any renewal, reinstatement, substitute, amended, altered, modified, or replacement policy with this Company or any affiliated Company, unless a named insured submits a written request to change the deductible and pays any additional premium that may apply.

I understand that in order for my deductible election to be valid, I must sign both this form and the enclosed form entitled "Important Information Regarding Personal Injury Protection Coverage Deductibles." If I do not return both forms, I understand that I will receive and be required to pay for Personal Injury Protection Coverage with no deductible.

The option I selected is checked below

PIP PremiumPIP PremiumPIP PremiumPIP Premium

Vehicle 1Vehicle 2Vehicle 3Vehicle 4

[ ] No deductible------

[ ] 250 deductible------

[ ] 500 deductible------

[ ] 1,000 deductible------

[ ] 2,000 deductible------

[ ] 5,000 deductible------

My Personal Injury Protection Coverage Applies to:

[ ] Named Insured Only

[ ] Named Insured and Members of Household

APPLICANT'S SIGNATUREPOLICY/BINDER NUMBER

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(If under 18, Guardian's Signature is required)

DATE:

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AIIC DE PIPELEC (10/04)