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COLORADO REJECTION OF MEDICAL PAYMENTS COVERAGE (Colonial General Insurance Agency, Inc)

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IL U 063 01 09
IL U 063 01 09
© Insurance Services Office, Inc., 2008
Page 1 of 1
COLORADO REJECTION OF MEDICAL
PAYMENTS COVERAGE
Policy Number:
Policy Effective Date:
Company:
Producer:
Applicant/Named Insured:
Colorado law permits you to reject Medical Payments Coverage. This document briefly describes this coverage
and the option to reject it.
You should read this document carefully and contact us or your agent if you have any questions regarding Medi-
cal Payments Coverage and the option to reject the coverage.
This document includes general descriptions of coverage. However, no coverage is provided by this document.
You should read your policy and review your Declarations Page(s) and/or Schedule(s) for complete information
on the coverages you are provided.
Medical Payments Coverage
Medical Payments Coverage provides insurance protection to an insured for reasonable medical expenses that
result from an automobile accident.
Unless rejected, Medical Payments Coverage will be provided at limits of at least $5,000 for each person injured
in an automobile accident.
Rejection Of Medical Payments Coverage
If you wish to reject Medical Payments Coverage, you may do so by initialing and signing below:
(Initials)
Signature Of Applicant/Named Insured
Date
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COLORADO REJECTION OF MEDICAL PAYMENTS COVERAGE (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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