Name
N-3546 (6/10)
Address
PERSONAL INJURY PROTECTION (NO-FAULT) COVERAGE
Maryland law requires that Personal Injury Protection (PIP) coverage be provided by commercial automobile insurance
policies issued In Maryland unless PIP coverage is affirmatively waived in writing by the First Named Insured.
We may not refuse to underwrite you because of a refusal to waive PIP coverage. We are required to issue your
policy with the Basic PIP benefits and limits described below unless you execute this written waiver.
PIP coverage provides payment of benefits at a minimum total aggregate limit of $2,500 per person per accident
for:
1.
reasonable and necessary medical expenses;
2.
85% of income loss; and
3.
reasonable and necessary expenses for essential services of non wage earners;
incurred within 3 years. PIP coverage applies to named insureds and individual named insureds' family members,
occupants of the covered auto, and pedestrians struck by the covered auto.
The premium cost of PIP coverage is:
.
You may waive PIP coverage for certain individuals by signing this waiver. Your waiver precludes those individuals
from receiving any PIP benefits under your policy.
1.
Individual Named Insureds.
If you are an individual, all PIP coverage will be excluded for named insureds listed on
the policy, any family member aged 16 or older, and all drivers shown on the Coverage Form.
2.
Other Than Individual Named Insureds.
If you are other than an individual, all PIP coverage will be excluded
forenamed insureds listed on the policy, and all drivers listed on the Coverage Form.
I
understand
that
my
coverage
election
shall
apply
on
the
policy
or
policies
in
effect
at
the
time
this
form
is
executed
and
all future renewal policies until I notify the Company IN WRITING of any changes.
My
signature
below,
and/or
payment
of
any
premiums
evidences
my
actual
knowledge
and
understanding
of
the
availability of these benefits and limits as well as the benefits and limits I have selected, rejected or accepted by default.
Signature of Named Insured
Date
COMMERCIAL AUTOMOBILE PERSONAL INJURY PROTECTION
WAIVER OF COVERAGE
MARYLAND
(To be completed and signed by Named Insured
)
click to sign
signature
click to edit
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