Hybrid Auto Discount. Anti Theft Discount. Deductible for You and household members 3. Bodily Injury Caused by an Uninsured Auto $100,000 Per Person,
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1 Personal Selections Page This Selections Page shows the coverages and discounts for your auto insurance policy issued by Insurance Company. This page, the attached endorsements and the Massachusetts Insurance Policy (2008 edition) form your policy. Your Policy #: ITEM 2. Policy Effective Dates: September 21, September 21, 2010 Your smitty123@aol.com (12:01 A.M. Eastern Standard Time) ITEM 1. Policy Issued to: Your Agent: Agent Code Jane Smith Breslin Insurance Agency 123 Any St 84 Court St Braintree MA Plymouth MA, smitty123@aol.com (508) 74 (508) ITEM 3. The following auto(s) are covered by this insurance policy: 1: 2009 Lexus Fancy 5FTNYF18418B : 2003 Toyota Camry 5FTNYF18418B05564 Policy Level s (These discounts apply to your entire policy.) Group 5% Agency Loyalty 5% Account Credit 10% Agency Loyalty 5% Renewal 6% gency Loyalty 5% Level s and s (These discounts apply to all or a portion of the premium for a specific auto.) Lease/Gap Hybrid Passive Restraint 1: Yes Yes 30% 10% 5% 25% 25% 2: 25% 25% 25% ITEM 4. This policy provides only the coverages for which a premium charge is shown. s, Parts Limits Premium 2- Limits Premium 1. Bodily Injury to Others 20,000 Per Person, 40,000 Per Accident Personal Injury Protection 8,000 Per Person Deductible for You 38 20,000 Per Person, 40,000 Per Accident 126 8,000 Per Person Deductible for You Bodily Injury Caused by an Uninsured 100,000 Per Person, 100,000 Per Person, Damage to Someone Else s Property 100,000 Per Accident ,000 Per Accident Optional Bodily Injury to Others 100,000 Per Person, 100,000 Per Person, Medical Payments Per Person Per Person 7. Collision 500 Deductible 500 Deductible Limited Collision Deductible Deductible 9. Comprehensive 500 Deductible 500 Deductible Substitute Transportation Up to 30 a day to a Up to 30 a day to a 51 maximum of 900 maximum of Towing and Labor Up to for each Up to 50 for each Bodily Injury Caused by an Underinsured 100,000 Per Person, 100,000 Per Person, Premium Subtotal 973 Premium Subtotal 988 Merit Rating Plan Adjustment 01 (112) 00 (95) 861 Policy: Page 1 of 2
2 Operator Name # Operator Attached Endorsements: SAT003 Special Endorsement SSA001 Endorsement MPY0016 Massachusetts Mandatory Endorsement SLL 002 /Lease Gap Endorsement ITEM 5. Garaging: 1: 123 Any Street, Braintree MA : 123 Any Street, Braintree MA ITEM 6. Lienholder- Additional Insured Information: 1: Honda Lease TRS*BX Sacramento CA : Honda Lease TRS*BX Sacramento CA Remarks: Address Change resulting in premium decrease of 72. Check carefully to ensure that the information listed on your Selections Page is correct. Are all operators listed? Failure to list a household member or any individual who customarily operates your auto may have very serious consequences. Are all your autos listed? Is the garaging correct? Are you receiving all the discounts you are entitled to? Is your mailing address correct? NOTICE: It is important for you to notify us of any changes that have occurred prior to the renewal of this policy and at any time during the policy period. Please review this Selections Page and the Massachusetts Insurance Policy (2008 Edition) carefully to ensure that you understand the coverages and limits contained in this policy. It is a crime to knowingly provide false or fraudulent information for the purpose of defrauding an insurance company. If you or someone else on your behalf has knowingly given us false, deceptive, misleading or incomplete information and if such false, deceptive, misleading or incomplete information increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance (Parts 5 thru 12) and we may cancel your policy. MERIT RATING PLAN The Merit Rating Board may verify the accuracy of the previous driving records of all listed operators. The Merit Rating Plan adjustment shown on the Selections Page for each auto is based on the driving records of the operators listed on your policy. Thank you for insuring your auto with Insurance ed. Page 2 of 2 Countersigned by:
3 Personal Selections Page This Selections Page shows the coverages and discounts for your auto insurance policy issued by Insurance Company. This page, the attached endorsements and the Massachusetts Insurance Policy (2008 edition) form your policy. Your Policy #: ITEM 2. Policy Effective Dates: September 21, September 21, Your (12:01 A.M. Eastern Standard Time) ITEM 1. Policy Issued to: Your Agent: Agent Code Jane Smith Breslin Insurance Agency 123 Any St 84 Court St Braintree MA Plymouth MA, smitty123@aol.com (508) 74 (508) ITEM 3. The following auto(s) are covered by this insurance policy: 1: 2009 Lexus Fancy 5FTNYF18418B : 2003 Toyota Camry 5FTNYF18418B05564 Policy Level s (These discounts apply to your entire policy.) Group 5% Agency Loyalty 5% Account Credit 10% Agency Loyalty 5% Renewal 6% gency Loyalty 5% Level s and s (These discounts apply to all or a portion of the premium for a specific auto.) Lease/Gap Hybrid 1: 2: afetyty Lease/GAP Hybrid Passive Restraint 1: 2: ITEM 4. This policy provides only the coverages for which a premium charge is shown. s, Parts Limits Premium 2- Limits Premium 1. Bodily Injury to Others 20,000 Per Person, 40,000 Per Accident Personal Injury Protection 8,000 Per Person Deductible for You 38 20,000 Per Person, 40,000 Per Accident 126 8,000 Per Person Deductible for You Bodily Injury Caused by an Uninsured 100,000 Per Person, 100,000 Per Person, Damage to Someone Else s Property 100,000 Per Accident ,000 Per Accident Optional Bodily Injury to Others 100,000 Per Person, 100,000 Per Person, Medical Payments Per Person Per Person 7. Collision 500 Deductible 500 Deductible Limited Collision Deductible Deductible 9. Comprehensive 500 Deductible 500 Deductible Substitute Transportation Up to 30 a day to a Up to 30 a day to a 51 maximum of 900 maximum of Towing and Labor Up to for each Up to 50 for each Bodily Injury Caused by an Underinsured 100,000 Per Person, 100,000 Per Person, Premium Subtotal 973 Premium Subtotal 988
4 Merit Rating Plan Adjustment 01 (112) 00 (95) Policy: 1754 Page 1 of 2 Operator Name Operator 1 2 Operator Name # Operator Attached Endorsements: SAT003 Special Endorsement SSA001 Endorsement MPY0016 Massachusetts Mandatory Endorsement SLL 002 /Lease Gap Endorsement ITEM 5. Alternate Garaging: (If blank, auto is garaged at the address shown on Page 1 of this Selection Page) 1: 123 Any Street, Braintree MA : 123 Any Street, Braintree MA ITEM 6. Lienholder- Additional Insured Information: 1: Honda Lease TRS*BX Sacramento CA : Honda Lease TRS*BX Sacramento CA Remarks: Address Change resulting in premium decrease of 72. Check carefully to ensure that the information listed on your Selections Page is correct. Are all operators listed? Failure to list a household member or any individual who customarily operates your auto may have very serious consequences. Are all your autos listed? Is the garaging correct?
5 Are you receiving all the discounts you are entitled to? Is your mailing address correct? NOTICE: It is important for you to notify us of any changes that have occurred prior to the renewal of this policy and at any time during the policy period. Please review this Selections Page and the MA Massachusetts Insurance Policy (2008 Edition) carefully to ensure that you understand the coverages and limits contained in this policy. It is a crime to knowingly provide false or fraudulent information for the purpose of defrauding an insurance company. If you or someone else on your behalf has knowingly given us false, deceptive, misleading or incomplete information and if such false, deceptive, misleading or incomplete information increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance (Parts 5 thru 12) and we may cancel your policy. MERIT RATING PLAN The Merit Rating Board may verify the accuracy of the previous driving records of all listed operators. The Merit Rating Plan adjustment shown on the Selections Page for each auto is based on the driving records of the operators listed on your policy. Thank you for insuring your auto with Insurance ed. Page 2 of 2 Countersigned by:
Safety Insurance AUTO. HOME. BUSINESS
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