Fill - Free fillable CANAL MARYLAND SUPPLEMENTAL APPLICATION 1. Applicant Name 2. (Risk Placement Services, Inc.) PDF form

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Form A-101 MD SUPP

Page 1 of 4

(8-2014)

CANAL

MARYLAND SUPPLEMENTAL APPLICATION

MUST be completed if Auto Liability Coverage is requested

INSURANCE COMPANY

INDEMNITY COMPANY

1. Applicant Name

2. DBA, if any

NOTICE: CANAL’S ACCEPTANCE OF THIS APPLICATION IS CONTINGENT UPON THE CONSIDERATION OF THE APPLICANT’S

CLAIMS HISTORY. IF ACCEPTED, YOUR CLAIMS HISTORY WILL ALSO BE CONSIDERED IN DETERMINING IF THE POLICY SHOULD

BE CANCELED OR NON-RENEWED.

MARYLAND FRAUD WARNING

Any person who knowingly or willfully presents a false or fraudule

nt claim for payment of a loss or benefit or who knowingly or

willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement

in prison.

UNINSURED MOTORISTS COVERAGE

Uninsured Motorists Coverage provides protection for persons who are legally entitled to reco

ver damages because of bodily

injury (including resulting death) or damage to property from an owner or operator of an uninsured motor vehicle or those whose

liability limits are less than the limits of your Uninsured Motorists Coverage.

In accordance with Maryland law, your commercial automobile liab

ility policy automatically includes Uninsured Motorists Coverage

at the Financial Responsibility Limits of $75,000 bodily injury and property damage combined single limit (CSL); or $30,000 each

person/ $60,000 each accident for bodily injury and $15,000 each accident for property damage unless you select higher limits of

Uninsured Motorists Coverage. Higher limits of Uninsured Motorists Coverage may be purchased at an additional premium

provided that the limits selected do not exceed the liability limits of the policy.

To be certain that the policy is issued with the Uninsured Mot

orists Coverage limits that you want, please indicate your desired

coverage limits below and sign and date this form, where provided, as your indication of approval of the limits selected.

I. DISCLOSURE OF UNINSURED MOTORISTS COVERAGE PREMIUMS

Limits Offered A

nnual Premium

30/60/15*

75 CSL

143

100 CSL

214

200 CSL

359

250 CSL

429

300 CSL

481

350 CSL

529

400 CSL

577

500 CSL

669

600 CSL

729

750 CSL

789

800 CSL

819

900 CSL

849

1,000 CSL

880

*Property Damage Uninsured Motorist Coverage is subject to a $250 per accident deductable.

Applicant’s Initials

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Form A-101 MD SUPP

Page 2 of 4

(8-2014)

II. OFFER OF UNINSURED MOTORISTS COVERAGE

I have had this coverage fully explained to me and I wish to purchase at Uninsured Motorists Coverage at the following

limits, which do not exceed the Liability Coverage limits of my policy (applicable item marked

Minimum Required by Law (select one below)

BI - $30,000 per person/$60,000 per accident; PD - $15,000 per accident; or

$75,000 combined single limit; or

The following HIGHER limit of liability (not to exceed policy liability limits)

$ ________________ combined single limit

III. APPLICANT’S ACKNOWLEDGMENT

he undersigner(s) hereby acknowledge(s) they have read, or have had read to them and understand, the above

explanations and offers of Uninsured Motorist Coverage. Selections have been made by checking the appropriate boxes in

Section II. The signature appearing below is that of the named insured or authorization has been given to the signer of this

Offer of Uninsured Motorist Coverage to select or reject coverage and limits on the behalf of the named insured.

YOUR SELECTION OR REJECTION OF COVERAGE IS BINDING ON ALL PERSONS INSURED UNDER THIS POLICY.

Applicant /Named Insured:

Date:

By:

Title:

Signature of Agent of Insured:

Date:

Address:

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Form A-101 MD SUPP

Page 3 of 4

(8-2014)

NOTICE CONCERNING THE WAVIER OF PERSONAL INJURY PROTECTION (PIP) COVERAGE IN MARYLAND

You have the choice of purchasing certain Personal Injury Protection (PIP) Coverages. Before deciding whether to purchase or

waive this coverage, please read the following carefully.

Full PIP coverage provides the following protection, without regarding to fault:

1. It covers you and members of your family residing with you who are injured in any m

otor vehicle accident; anyone injured

while in your vehicle; and pedestrians injured by your vehicle.

2. The minimum coverage is $2,500 and may be used to cover:

a. All reasonable and necessary medical expenses incurred within 3 years of injury; and

b. 85% of actually incurred lost wages; or

c. If the injured person is not employed at the time of injury, any reasonable and necessary expenses to provide

for essential services which that person would have provided for the care and maintenance of his or her

family or household.

If you do not sign

the waiver, you will automatically receive the full PIP protection described above. Your PIP premium will be

annually.

You may only waive PIP coverage for:

1. The named insured (you);

2. Al

l listed drivers on the policy; and

3. Members of your family who are 16 years of age or older and reside with you in your household.

The waiver prevents the named insured (y

ou) from collecting PIP benefits under any motor vehicle liability insurance policy

issued in the State of Maryland or another form of security authorized to be used in place of a motor vehicle liability insurance

policy.

The waiver prevents individuals described in cate

gory 2 or 3 above from collecting PIP benefits under your policy. In addition, the

waiver prevents these individuals from collecting benefits under any other policy of motor vehicle liability insurance issued in the

State of Maryland or another form of security authorized to be used in place of a motor vehicle liability insurance policy unless the

individual:

x Is the first named insured under the other policy;

x Has

not waived PIP benefits under the other policy; and

x Is not a named insured under any policy of motor vehicle liability insurance where a waiver of PIP benefits is in effect.

The waiver does not impair the rights of ot

her individuals such as pedestrians or minor children from collecting PIP under your

policy.

If you decide to sign the waiver, your PIP premium will be

of the full PIP coverage. The total premium will be

annually.

If you decide not to sign the waiver, your insurance company may not refuse to write your insurance coverage.

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Form A-101 MD SUPP

Page 4 of 4

(8-2014)

WAIVER OF PERSONAL INJURY PROTECTION (PIP) COVERAGE

I hereby confirm that I have fully read and understood the attached notice, required by Section 19-506 of the Insurance

Article, and I understand and agree that the Company indicated below, in reliance upon my signature as the first named

insured/applicant, will NOT provide the Personal Injury Protection (PIP) coverage required by Section 19-505 and

described in the attached notice provided to me with this waiver. This coverage is waived for any injury which may be

sustained by:

1. Anyone listed as a named insured on the policy;

2. All drivers listed on the policy; and

3. All members of the named insured’s family living in the insured’s household who are 16 years of age or older.

I further understand and agree that the waiver of Personal Injury

Protection (PIP) benefits under the policy being applied

for waives coverage for PIP benefits for anyone described above under any other policy issued in the State of Maryland

or another form of security authorized to be used in place of a motor vehicle liability insurance policy, unless the

individual is:

x Is the first named in

sured under the other policy; and

x Has not waived PIP benefits under the other policy; and

x Is not a named insured under any policy of motor vehicle liability insurance where a waiver of PIP benefits is in

effect.

I, the first named insured/applicant, have fully read and unders

tood the above noted information and hereby:

(check one of the following)

request full PIP coverage be applicable to the policy or binder of insurance described below, on all future renewals of

the policy and on all replacement policies unless I notify the company in writing to the contrary, with the effective date of

such change being no earlier than the receipt date by the company of my written notification.

affirmatively waive the benefits required by Section 19-505 of the Insurance Article (PIP). I understand and agree that

this waiver of coverage shall be applicable to the policy or binder of insurance described below, on all future renewals of

the policy and on all replacement policies unless I notify the company in writing to the contrary, with the effective date of

such change being no earlier than the receipt date by the company of my written notification.

Print Name:

First Named Applicant/Insured

Signature:

Signature of First Named Applicant/Insured

Date:

Policy/Binder #:

Insurer:

Producer Name:

Producer Code:

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CANAL MARYLAND SUPPLEMENTAL APPLICATION 1. Applicant Name 2. (Risk Placement Services, Inc.)

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