M-5363 (11/2008)
M-5363 (11/2008)
FLORIDA PERSONAL INJURY PROTECTION (PIP) OPTIONS
For personal injury protection insurance, the named insured may elect a deductible and to exclude
coverage for loss of gross income and loss of earning capacity (“lost wages”). These elections
apply to the named insured alone, or to the named insured and all dependent resident relatives. A
premium reduction will result from these elections. The named insured is hereby advised not to
elect the lost wage exclusion if the named insured or dependent resident relatives are employed,
since lost wages will not be payable in the event of an accident.
Deductible Options
Ƒ I do not want a deductible to apply to my policy’s Personal Injury Protection coverage
Ƒ I do
want a deductible to apply to my policy’s Personal Injury Protection coverage in the
manner chosen below
Deductible
Amount
Named Insured
Only
Named Insured and All
Dependent Resident Relatives
$250 ƑƑ
$500 ƑƑ
$1000 ƑƑ
Exclusion of Work Loss Benefits Options
Ƒ Exclude Work Loss benefits for the Named Insured and All Dependent Resident
Relatives
Ƒ Exclude Work Loss benefits only for Named Insured
By signing, I understand and agree that selection of the above options applies to my liability
insurance policy and future renewals or replacements of such policy. If I decide to select another
option at some future time, I must let the company or my agent know.
# #
Named Insured or representative for all insureds Date
click to sign
signature
click to edit
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