Fillable FIRST PARTY BENEFITS NOTICE (Risk Placement Services, Inc.)

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FIRST PARTY BENEFITS NOTICE (Risk Placement Services, Inc.)

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M-3618j Pennsylvania (05/2008)
M-3618j Pennsylvania (05/2008) Page 1 of 2
FIRST PARTY BENEFITS NOTICE
The options that you requested for Pennsylvania First Party Benefits are reproduced below. These options
determined your policy premium, but your policy may be changed by contacting the party listed below.
Changing these indications may result in changes to your premium. The State of Pennsylvania requires you to
purchase a minimum of $5,000 for the Medical Expense Benefit. All of the other options listed below (including a
higher limit of Medical Expenses) are choices you may make. The premium associated with each option is also listed.
If you are satisfied with your level of First Party Benefits this notice may be disregarded.
FIRST PARTY BENEFITS
A. MEDICAL EXPENSE BENEFIT Coverage to reimburse you for reasonable and necessary medical treatment
and services incurred.
B. INCOME LOSS BENEFIT Coverage to replace a portion of lost income and reimburse you for
expenses in securing replacement services.
C. ACCIDENTAL DEATH BENEFIT A death benefit paid in the event of the death of an insured person due to a
covered auto accident.
D. FUNERAL BENEFIT Coverage to pay for direct funeral, burial and other related expenses
incurred as a result of the death of an insured person due to a covered
accident.
BENEFIT LEVEL OPTIONS:
(Coverage is comprised of a selection from each one of A, B, C, and D or one selection
from E. Coverage is also comprised of a selection from F.)
A. MEDICAL EXPENSES:
(_ indicates the option you selected)
$5,000 per person, per accident (Minimum) $ Premium
$10,000 per person, per accident $ Premium
$25,000 per person, per accident $ Premium
$50,000 per person, per accident $ Premium
$100,000 per person, per accident (Maximum) $ Premium
B. INCOME LOSS:
(_ indicates the option you selected, if any)
None – Rejected per month / per accident, per person (Minimum)
$1,000 / $5,000 per month / per accident, per person $ Premium
$1,000 / $10,000 per month / per accident, per person $ Premium
$1,000 / $15,000 per month / per accident, per person $ Premium
$1,500 / $25,000 per month / per accident, per person $ Premium
$2,500 / $50,000 per month / per accident, per person (Maximum) $ Premium
M-3618j Pennsylvania (05/2008)
M-3618j Pennsylvania (05/2008) Page 2 of 2
C. ACCIDENTAL DEATH: (_ indicates the option you selected, if any)
None – Rejected per person, per accident (Minimum)
$5,000 per person, per accident $ Premium
$10,000 per person, per accident $ Premium
$25,000 per person, per accident (Maximum) $ Premium
D. FUNERAL EXPENSE:
(_ indicates the option you selected, if any)
None – Rejected per person, per accident (Minimum)
$1,500 per person, per accident $ Premium
$2,500 per person, per accident (Maximum) $ Premium
OR
E. COMBINATION BENEFITS: Single Limit for all coverages, with specific benefit limits as shown
(_ indicates the option you selected, if any)
$50,000 ($2,500 Funeral and $10,000 Accidental Death Benefits) $ Premium
$100,000 ($2,500 Funeral and $10,000 Accidental Death Benefits) $ Premium
$177,500 ($2,500 Funeral and $25,000 Accidental Death Benefits) $ Premium
AND
F. EXTRAORDINARY MEDICAL BENEFIT (EMB): (_ indicates the option you selected, if any)
In accordance with Pennsylvania Law your First Party Benefits coverage may be extended to provide an
extraordinary medical benefit (EMB) which will pay the medical and rehabilitation costs for you and your family
members residing in your household which are more than $100,000 for each person injured as the result of an
automobile accident, up to a lifetime benefit limits of $1,000,000 for each person. Since you are only required to
carry $5,000 medical expense coverage under your First Party Benefits and EMB coverage only pays expenses
that exceed $100,000, you may have a gap in coverage between your requested First Party Benefits and EMB
coverage. We recommend you consider this when you make your medical expense selections.
I purchased no EMB coverage.
I purchased EMB coverage at the following limit:
$100,000 $300,000 $500,000 $1,000,000
If you desire to change your coverage please contact:
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FIRST PARTY BENEFITS NOTICE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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