Fillable FORM A: REQUIRED STATEMENT TO POLICYHOLDERS DELAWARE MOTORISTS (Risk Placement Services, Inc.)

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FORM A: REQUIRED STATEMENT TO POLICYHOLDERS DELAWARE MOTORISTS (Risk Placement Services, Inc.)

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M-5356a (03/2009)
M
-5356a (03/2009) Page 1of2
DELAWARE MOTORISTS PROTECTION ACT
REQUIRED STATEMENT TO POLICYHOLDERS
FORM A
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.
•
B
odily Injury Liability: ($15,000 each person; $30,000 each accident)
• P
roperty Damage Liability: ($10,000 each accident)
• P
ersonal Injury Protection: ($15,000 each person; $30,000 each accident)
• Dam
age to Property Other Than a Motor Vehicle: ($10,000)
INSURE
D
POLICY NUMBER COMPANY
EFFECTIVE DATE EXPIRATION DATE
A. COVERAGES
B
.
OP
TIONS
(YOU MUST SELECT LIMITS AND
COVERAGE DESIRED)
C.
SE
LECTIO
N
1. BODILY INJURY AND
PROPERTY DAMAGE
LIABILIT
Y
(Compulso
ry)
(Split limits OR
Co
mbined Singe Limit)
I WANT
1.
Li
mits as Shown in Column C
2.
M
inimum Limits
Split Bodily Injury Limits
Each Person Each Accident
$
$
Property Damage Limit per Accident
$
-OR-
Combined Single (BI & PD) Limit
$
2. NO-FAULT
(Compulso
ry)
(Additional Pers
onal
Injury Protection
available by select
ing
higher limits
)
I WANT
Additional Limits as Shown in Column C
Minimum Limits:
Deductible: No deductibles available
Additional Personal Injury
Protection Limits
Each Person Each Accident
$
$
-OR-
Combined Single Limit $
Minimum Limits/No Deductible
cost
Additional Limits/No Deductible
cost
3. PHYSICAL
DAMAGE
I WANT
1.
Colli
sion
2.
Co
mprehensive or Specified Causes of Loss:
Com
prehensive
Specified Causes of Lo
ss
3.
To Reject This Coverage Entirely
Deductibles
Collision $
Comprehensive / Specified Causes of Loss
$
M-5356a (03/2009)
M-5356a (03/2009) Page 2of2
4. UNINSURED /
UNDERINSURED
VEHICLE
COVERAGE*
(Optional) (Available in
Limits up to the Bodily
Injury Liability Limits or
$100,000/300,000
whichever is less)
I WANT
1. Minimum Limits ($15,000/30,000)
2. Bodily Injury Liability Policy Limit
3. Other – Specify in Column C
4. To reject this coverage entirely
Uninsured / Underinsured Limits
Each Person Each Accident
$
$
-OR-
Combined Single Limit
$
*Uninsured/Underinsured Motorist 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.
My selection of 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 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 lesser or greater premium that may apply to such change.
Signature of Named Insured 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 a change of vehicle or coverage or because of an
interruption of coverage, unless I subsequently request such coverage in writing.
Signature of Named Insured 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 coverage, or other additional coverages which may be available from the
company.
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FORM A: REQUIRED STATEMENT TO POLICYHOLDERS DELAWARE MOTORISTS (Risk Placement Services, Inc.)

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Completed 23 November 2020

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