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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION VIRGINIA (Risk Placement Services, Inc.)

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Name
N-3584 (6/10)
Address
Page 1 of 2
SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION
VIRGINIA
(To be completed and signed by Named Insured
)
UNINSURED AND UNDERINSURED MOTORISTS COVERAGE
Uninsured and Underinsured Motorists Coverage provides protection against bodily injury or property damage caused
by a driver who has no insurance coverage, is denied insurance coverage, is a hit-and-run driver or a driver of an
underinsured motor vehicle. An underinsured motor vehicle is one where the total amount of bodily injury and property
damage coverage applicable to the operation of the motor vehicle, and available for payment, is less than the total
amount of uninsured and underinsured motorists coverage afforded any person injured as a result of the operation or
use of a motor vehicle. Refer to your policy for the prevailing coverage provisions.
In accordance with the laws of Virginia, your automobile liability or motor vehicle liability policy, shall
automatically
include Uninsured and Underinsured Motorists Coverage at limits equal to the Bodily Injury and Property Damage
Liability policy
limits,
unless
you choose lower limits as indicated below, but not less than the Financial Responsibility
Limits of $25,000/$50,000 for Bodily Injury, or $20,000 for Property Damage Split Limits; or $70,000 Combined Single
Limits (CSL). School busses transporting ten or more pupils or personnel are required to maintain Financial
Responsibility Limits of at least $50,000/$200,000 for Bodily Injury, or $20,000 for Property Damage Split Limits.
Please make your selection below:
I wish to select Financial Responsibility Limits. The Uninsured and Underinsured Motorists Coverage limits will be
either split (each person/each accident) or combined single limit (CSL), consistent with the policy Bodily Injury and
Property Damage Limits.
I wish to select Uninsured and Underinsured Motorists Coverage at limits less than the Bodily Injury and Property
Damage Liability policy limits, but greater than the Financial Responsibility Limits. (Specify)
$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)
$
N-3584 (6/10)
Page 2 of 2
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, rejected or accepted by default.
Signature of Named Insured
Date
MEDICAL EXPENSE BENEFITS AND INCOME LOSS BENEFITS
MEDICAL EXPENSE BENEFITS
In accordance with the laws of Virginia, you have the option to purchase Medical Expense Benefits up to $2,000 per
person, covering yourself or a designated individual or for occupants of a covered auto. You may choose not to
purchase this coverage or choose other limits. Please make your selection below:
I elect to purchase Medical Expense Benefits at the following limit:
$500 per person
$1,000 per person
$2,000 per person
$5,000 per person
Other limit (please specify) $
each person
Medical Expense Benefits are to apply to the following designated individual:
I choose not to purchase Medical Expense Benefits.
INCOME LOSS BENEFITS
You have the option to purchase Income Loss Benefits covering injured persons except while, in the course of their
employment, they are occupying a Public or livery conveyance or commercial auto or engaged in duties incident to the
repairs or servicing of autos.
I elect to purchase Income Loss Benefits for $100 per week, not to exceed 52 weeks.
I choose
not
to purchase Income Loss Benefits.
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SUPPLEMENTARY COMMERCIAL AUTOMOBILE APPLICATION VIRGINIA (Risk Placement Services, Inc.)

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Completed 23 November 2020

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