Name
N-3520 (7/10)
Address
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
MARYLAND
(To be completed and signed by Named Insured
)
UNINSURED MOTORISTS COVERAGE
Uninsured
Motorists
Coverage
provides
protection
against
damages
the
insured
is
legally
entitled
to
recover
from
the
owner
or
driver
of
an
uninsured
motor
vehicle.
An
uninsured
motor
vehicle
is
a
vehicle:
(1)
for
which
there
is
no
liability
policy
or
other
security
providing
at
least
the
amounts
required
by
law;
(2)
for
which
the
sum
of
the
limits
of
liability
under
all
applicable
policies
and
securities
(a) is less
than
your
Uninsured
Motorists
Coverage
limits,
or
(b)
has
been
reduced
by
payment
to
other
persons
inured
in
the
same
accident
to
an
amount
less
than
your
Uninsured
Motorists
Coverage
limits;
(3)
for
which
the
insurer
denies
coverage
or
is
insolvent;
or
(4)
that
is
a
hit
and
run
vehicle.
Refer
to
your
policy
for
the prevailing coverage provisions.
In
accordance
with
the
laws
of
Maryland,
your
commercial
automobile
liability
or
motor
vehicle
liability
policy
shall
automatically
include
Uninsured
Motorists
Coverage
at
the
Financial
Responsibility
Limits
of
$
75,000
bodily
injury
and
property
damage
combined
single
limit
(CSL);
or
$
30,000
each
person/$
60,000
each
accident
for
bodily
injury
and
$15,000
each
accident
for
property
damage
unless
you
select
higher
Uninsured
Motorists
Coverage
limits,
but not
to
exceed
your
policy’s
liability
limits.
(Property
Damage
Coverage
is
subject
to
a
$250
deductible*.)
The
Uninsured
Motorists
Coverage
limits
will
be
either
split
(each
person/each
accident)
or
a
combined
single
limit
(CSL)
consistent
with the liability limits on your policy.
If you wish to select higher Uninsured Motorists Coverage limits, please indicate below:
I wish to select limits equal to my policy's liability limits.
I wish to select limits lower than my policy's liability limits, but greater than the Minimum Financial Responsibility
Limits (Specify limits):
$ 100,000 each accident (CSL)
$ 250,000 each accident (CSL)
$ 300,000 each accident (CSL)
$ 350,000 each accident (CSL)
$ 500,000 each accident (CSL)
$ 750,000 each accident (CSL)
$ 1,000,000 each accident (CSL)
$
(CSL)
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 or accepted by default.
Signature of Named Insured
Date
*IF YOU HAVE ELECTED TO PURCHASE A DEDUCTIBLE RATING PLAN, THE DEDUCTIBLE RATING PLAN
AMOUNT SHOWN ON THE DEDUCTIBLE ENDORSEMENT IN YOUR POLICY SHALL APPLY AS YOUR
UNINSURED MOTORISTS COVERAGE PROPERTY DAMAGE DEDUCTIBLE.
click to sign
signature
click to edit
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