Pennsylvania - Supplement to Commercial Vehicle Application
NOTICE
As a result of changes to the automobile insurance laws of the Commonwealth of Pennsylvania, several new coverage options are available to you, as part of your policy. These new coverages and the options available to you are called "First Party Benefits" (because they are paid to you) and are explained below.
First Party Benefits
A.Medical Expense Benefit -Coverage to reimburse you for reasonable and necessary medical treatment and services incurred due to a covered auto accident.
B.Income Loss Benefit -Coverage to replace a portion of lost income and reimburse you for expenses in securing replacement services due to a covered auto accident.
C.Accidental Death Benefit -A death benefit paid in the event of the death of an insured person due to a covered auto accident.
D.Funeral Benefit -Coverage to pay for direct funeral, burial and other related expenses incurred as a result of the death of an insured person due to a covered auto accident.
You may have limits options available to you for each of these First Party Benefits. To be certain that we issue your policy with the Benefits of your choosing, you must indicate your choice of the options shown below for each coverage. Then date and sign the form where shown and return it to your Agent.
BENEFIT LEVEL OPTIONS: (include your choice by marking the box “X” for each coverage or for your choice of Combination Benefits Option):
A.MEDICAL EXPENSES per person, per accident: (“X” indicates your choice)
$5,000 $10,000 $25,000 $50,000 $100,000
B.INCOME LOSS per person, per accident: (“X” indicates your choice)
$1,000 per month/$5,000 total benefit $1,000 per month/$15,000 total benefit
$1,500 per month/$25,000 total benefit $2,500 per month/$50,000 total benefit
None
C.ACCIDENTAL DEATH per person, per accident: (“X” indicates your choice)
None-Rejected $1,000 $5,000 $10,000 $25,000
D.FUNERAL EXPENSE per person, per accident: (“X” indicates your choice)
$1,500 $2,500 None
E.COMBINATION BENEFITS: Single Limit for all coverages, per person, per accident with specific benefit limits as shown (“X” indicates your choice).
$17,500($2,500 Funeral and no Accidental Death Benefits)
$50,000($2,500 Funeral and $10,000 Accidental Death Benefits)
$100,000($2,500 Funeral and $10,000 Accidental Death Benefits)
$177,500($2,500 Funeral and $25,000 Accidental Death Benefits)
AND
Your first party benefits coverage may be extended to provide an extraordinary medical benefit (EMB) which will pay the medical and rehabilitation costs for you and your family members residing in your household which are more than $100,000 for each person injured as the result of an automobile accident, up to a lifetime benefit limits of $1,100,000 for each person. Since you are only required to carry $5,000 medical expense coverage under your first party benefits and EMB Coverage only pays expenses that exceed $100,000 you may have a gap in coverage between your selected first party benefits above and EMB coverage. We recommend you consider this when you make your medical expense selections.
F.EXTRAORDINARY MEDICAL BENEFIT (EMB): (“X”indicates your choice)
I wish to purchase EMB coverage.
I do not wish to purchase EMB coverage.
I have had the coverages, benefit levels and options as set out above fully explained to me and have indicated my choices (“X” indicates my choices) as shown. I understand that this is simply a summary of the coverages and benefits, and that the forms and endorsements attached to my policy actually make up my coverage.
______
Date Signature of Named Insured (s)
______
Named Insured (please type or print name)
The choices and options as indicated above will continue in force and effect until replacement written notice is received by the company or its representative.
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