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FORM A: CANAL DELAWARE SUPPLEMENTAL APPLICATION MUST be (Risk Placement Services, Inc.)

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THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 DE SUPP Page 1 of 2 (Rev. 12-2014)
DELAWARE SUPPLEMENTAL APPLICATION
MUST be completed if Auto Liability Coverage is requested
1. Applicant Name
2. DBA, if any
COMMERCIAL AUTO
FORM A
DELAWARE MOTORISTS PROTECTION ACT
REQUIRED STATEMENT TO POLICYHOLDERS
Canal Insurance Company
P.O. Box 7
Greenville, South Carolina 29602
The owner of a motor vehicle registered in the State of Delaware is required to purchase at least the following minimum insurance
coverages and limits of liability under the Delaware Motorists Protection Act
Bodily Injury Liability ($15,000 each person, $30,000 each accident)
Property Damage Liability ($10,000 each accident)
Personal Injury Protection ($15,000 each person, $30,000 each accident)
Damage to Property Other Than a Motor Vehicle ($10,000)
INSURED POLICY NUMBER CO.
EFF: EXP: VEHICLE:
A. COVERAGES
B. OPTIONS
YOU MUST SELECT LIMITS AND
COVERAGE DESIRED C. SELECTION
1. BODILY INJURY I WANT: Bodily Injury Limits
LIABILITY 1. Minimum Limits ($15,000/$30,000) Each Person Each Accident
(Compulsory) 2. Limits as shown in Column C
$,000 $,000
2. PROPERTY DAMAGE I WANT: Property Damage Limits
LIABILITY 1. Minimum Limits ($10,000)
(Compulsory) 2. Limits as shown in Column C $,000
3. COMBINED SINGLE LIMITS (CSL) Bodily Injury and Property
LIABILITY (BODILY INJURY) I WANT: Damage Liability
AND PROPERTY DAMAGE 1. Limits as shown in Column C
$,000CSL Each
Accident
4. NO-FAULT I WANT: (Additional Personal Injury
(Compulsory) 1. Minimum Limits ($15,000/$30,000) Protection Limits Not Available)
2. Full coverage with no Deductible Yes
No
Full coverage premium $
3. Deductible applicable to Named Insured only Deductible
Amount Cost Per Unit
$250
$500
$1,000
4. Deductible applicable to Named Insured and
$250
Members of his household
$500
$1,000
(Note: Deductible applicable per Accident – not per Person)
CANAL
INSURANCE COMPANY
INDEMNITY COMPANY
THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER THIS IS NOT A BINDER
Form A-101 DE SUPP Page 2 of 2 (Rev. 12-2014)
A. COVERAGES B. OPTIONS
YOU MUST SELECT LIMITS AND
COVERAGE DESIRED
C. SELECTION
5. PHYSICAL I WANT: DEDUCTIBLE
DAMAGE 1. Collision
To Reject This Coverage Entirely $_______________
2. Comprehensive
To Reject This Coverage Entirely $_______________
6. UNINSURED/ I WANT: LIMITS
UNDERINSURED 1. Minimum Limits ($15,000/$30,000 UMBI)
VEHICLE ($10,000 UMPD) Each Person
COVERAGE* 2. Bodily Injury Liability Policy Limit
3. Other – Specify in Column C Each Accident
4. To reject this coverage entirely
*(Optional) (Available
Uninsured/Underinsured Motorists Coverage is not mandatory, but it is required that the coverage
be offered to all policyholders. This coverage is designed to pay damages for injuries that could
be received in accidents caused by drivers of uninsured and underinsured vehicles. This
includes $10,000 Property Damage Coverage which applies only to accidents with uninsured
vehicles and is subject to a $250 deductible.
In limits up to the Bodily
Injury Liability Limits or
$100,000/$300,000
Whichever is less)
My selection of a PIP (No-Fault) deductible or no PIP (No-Fault) deductible at the cost stated above is based on the information provided to me
by the insurer. I understand and agree that my selection of a PIP (No-Fault) deductible or no PIP (No-Fault) deductible shall be binding on me
and all persons subject to the terms of this policy. My selection shall apply to any renewal, reinstatement, substitute amended, altered, modified
or replacement policy with this or any affiliated or successor company unless I or a named insured shall submit a written request to change the
deductible and pay such lessor or greater premium that may apply to such a change.
Signature of Named Insured
X
Date
I understand my policy will be issued to reflect the options I have chosen with respect to the coverages shown under Column A above.
I further understand and agree that my selection of the Uninsured/Underinsured Motor Vehicle Coverage option, as shown above, shall be
applicable to the policy of insurance on the vehicle described on all future renewals of the policy, on future policies issued me because of an
interruption of coverage, unless I subsequently request such coverage in writing.
Signature of Named Insured
X
Date
Agent’s Name
It is not the intent of this statement to limit or discourage the purchase of increased limits of liability and personal injury protection coverages, or
other additional coverages which may be available from the company.
TO BE SIGNED BY NON-STANDARD POLICYHOLDERS
My agent has informed me that I am considered a non-standard driver and has notified me of the availability of the Delaware Automobile
(“Assigned Risk”) Insurance Plan, which provides less expensive automobile insurance for some drivers.
Signature of Named Insured:
X
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FORM A: CANAL DELAWARE SUPPLEMENTAL APPLICATION MUST be (Risk Placement Services, Inc.)

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Completed 23 November 2020

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