CanalTruckInsuranceApplicationMARYLAND
InsuranceIndemnitySections1 through6 mustbe completedforaquote indication.Sections7 through9 must be completed inordertobind.
1.GeneralInformationApplicantLegal Name / Formof Business
IndividualLLCPartnershipCorporationJoint VentureTrust
Company Name(DBA)(if any) / PrincipalorMajority Owner(pleaseincludeallprincipals)
TaxIdentificationNumberorSocialSecurity Number (Ifprovided,certificatesof insurancemaybe accessedfrom hoursaday)
Locationof Business Premises orPhysicalAddress / TelephoneNumber / Mobile PhoneNumber
City / State / ZipCode / County
LocationIs:InsideCity LimitsOutsideCity Limits
Mailing Address(ifdifferent thanabove)
City / State / ZipCode / County
Pleaseenterthemonthandyearthe currentoperationsbegan:Month:Year:
PolicyType / Scheduled VehicleGrossReceiptsGrossMileage
Business
Class / ForHireTruckingPrivateCarrierNonTrucking
For-Hire andPrivate Operations / AutoorBoatContainerDrive-AwayDry BulkorFarmProductsDry Van/ BoxDry Van-DoublesDump
Dump-CoalFlatbedLivestockLogor PulpMobileHomeRefrigeratedSpecialTypeOperations
Tanker-FuelTanker-Liquids orCompressed GassesTowingandRecoveryWaste/ Garbage
CommoditiesTransported(Pleasebespecific -generalfreightandmiscellaneous is not acceptable)
%Commodity%Commodity
Pleaseenterthepercentageof loadsreceived fromabroker:
Indicate PolicyTermandPaymentMethod
Short TermPolicy: DesiredExpirationDate (nopayment planavailableforshorttermpolicies) AnnualPolicy:FullPayment toCompany Company Payment Plan
FinancedthroughoutsidePremiumFinanceCompanywithfullpaymentto Canal(nodoublefinancingpermitted–attachcontract)
Continuous Until CancelledPolicy(2monthescrowdeposit andmonthly billing)
2. MotorCarrierFilings
MCS-90Requested:YesNo / AuthorityType:CommonContractBrokerage
MC# / DOT#
3. History
Havetherebeenanylosses inthecurrentyearorthepastthreeyears?YesNo Ifyes,pleasecompletebelow.
Pleasecompleteforalllinesofbusiness forthecurrentyear,aswellas forthe threeyearsprior, or submit loss runs.
Year / Liability
#Claims*Amount Incurred / PhysicalDamage
#Claims*Amount Incurred / Cargo
#Claims*Amount Incurred / GeneralLiability
#Claims*Amount Incurred
Pleaseenterthenumberof claims over$100,000: / Pleaseenterthedollaramount forclaims over$100,000:
Lossrunsarerequiredfor allapplicantswithfiveormore power units.Attachseparateloss runsifspaceprovidedisnotsufficient.*Amountincurred shouldincludeamountspaid,reservedtotalsas wellasanyexpenses.
4. DriversIdeclare thefollowinglist includes alldrivers of vehiclesrequestedtobe coveredunder thepolicy includingemployees, leasedemployees, owner operators, mechanics, familymembers,andany otherpersonallowed todriveaninsuredvehicle.
Driver Name / Yearsof
Experience / ConvictionsandMVR Record / DriverLicense
Number / License
State / Year
Hired / Dateof
Birth
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage1of6(9-2009)
CanalTruck Insurance Application
5. VehiclesDescriptionofVehicles(trailers mustbescheduled forliabilitycoverage toapply whiledetachedfromacoveredpowerunit)
Unit
No. / Model
Year / Makeand UnitType / VehicleIdentification
Number
(VIN) / GVW / Radius / *Stated
Value / Gap Coverage (Y/N) / **Is
garaging address sameas
physical?
(Y/N)
1
2
3
4
5
*Onlyapplicableif PhysicalDamage coverageis appliedfor. **Ifaunitisnotgaragedat thephysicaladdress, itisnecessary tolist thegaraging
addresses intheAdditional Underwriting Informationsectionof thisapplication.
6.Coverage
Coverages Desired:AutoLiabilityAutoPhysical DamageMotorTruckCargoTruckersGeneralLiability
Auto LiabilityCoverageSelectionCombinedSingleLimit-eachaccident
$
IfapplyingforHiredAutocoverage,pleaseentertheannualestimated cost ofhire:
IfNon-Owned coverageis desiredpleaseenter thenumberofemployees: Is thisasocialserviceagencyorcharitableorganization? Yes No
Auto PhysicalDamageCoverageSelection
DeductibleDesired
$500$1,000$2,500$5,000 / CoverageDesired
Collisionand SpecifiedCausesof LossCollisionandComprehensive(whereavailable)
AdditionalAutoPhysicalDamageCoveragesDesired
AdditionalTowingLimit$(in theevent ofatotalloss tothedescribedunit)$2,500included
Trailer InterchangeLimit$Minus$1,000Deductible(UIIA containerhaulers)
Non-OwnedTrailerLimit$Minus$1,000Deductible(coverageapplies only whileattached toascheduledpowerunit)
MotorTruckCargo CoverageSelection
Pleaseselectthedesiredform:StandardPreferred
LimitDesirePerVehicle$ / DeductibleDesired$500$1,000$2,500$5,000
Units that require specific limits other thanabove,pleaseindicatebelow.
UnitNo.DesiredLimitUnitNo.DesiredLimit
$ / $
Additional CargoCoveragesorEndorsementsDesired
Refrigeration Breakdown-$2,500minimumdeductiblerequiredRemovalofCoinsuranceClauseRemovalofCommodities Theft
EarnedFreight Increaseto $($1,000included)DebrisRemovalIncrease to$($25,000included)
Loss MitigationIncreaseto($7,500included)Reusable PackingContainerIncrease to $($5,000included)
TruckersGeneralLiabilityCoverageSelectionThisis forbusinesses solely involvedin“for-hire” transportationof property
DesiredLimitsGeneralAggregate-pleaseselect one$1,000,000$2,000,000EachOccurrence $1,000,000(included)
EmployersLiability(StopGap)Coverage-Applicableonly inND, OH,WA andWY. Pleaseselect eitheryesorno.
Yes / No$1,000,000 / Bodily Injury byAccident-eachaccident / $1,000,000 / Bodily Injury by Disease-eachemployee$1,000,000 / Bodily Injury by Disease-eachpolicy
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage2of6(9-2009)
CanalTruck Insurance Application
7.AdditionalUnderwritingInformation
Haveanydriversbeenconvictedofanyofthefollowing?YesNo
Negligenthomicide, unlawfuluseofvehicle, speedcontest orracing,reckless driving, leaving thesceneofanaccident orahitandrun,any felony convictionwhichinvolves amotorvehicle, speedtwenty miles ormoreover thespeedlimit ordrivingwhilelicenseissuspendedorrevokedina commercial vehicle,DUI orDWI.
Ifyes, pleaseprovidedrivername, convictiondateanddetails:
Pleasecompleteall ofthefollowing:
Yes Yes Yes Yes Yes / No No No No No / Doyouownany otherbusinesses?Have therebeenany changes intheownership, management ornameof theoperationinthepast fiveyears? Areallownedandoperatedpowerunitslistedonthisapplication?
Doyouhaveanymobileequipment subject tofinancial responsibility laws?
Doyouact as afreight forwarder,freightbrokerorarrangeloads forothers?
Yes / No / Doyouleasetoothers?
Yes / No / Doyouhauldouble trailers?
Yes / No / Doyouhaultripletrailers?
Yes / No / Doyouallowguestpassengers?
Yes / No / Areany vehiclesusedtotransport employees?
Yes / No / Doyouhireowneroperatorsonatripleasebasis?
Yes / No / Doyoulend,leaseorrenttrucks, tractors or trailers tootherswithout drivers?
Yes
Yes / No
No / Doyouagree toreportalldrivers toyouragentprior tothemdrivinganinsuredunit?
Doyou complywithallDOT regulations concerningdriveremployment, filesandregulations?
IfapplyingforNon-TruckingCoveragelist nameandthemotorcarriernumberof thelessee towhomyouarepermanently leased.
Nameof MotorCarrier:MotorCarrierNumber:
FilingsRequested / MotorCarrier# / Applicant’sNameandAddress ExactlyAs ItAppearsOnEachPermitLiabilityBMC91XCargo BMC34 / MC
Liability–FormE State
Oversized/Overweight
Hazardous
Cargo–FormH State
SR22-If yes explain
Pleasenote: TheFMCSA and/orstateagencies requireaminimum36day noticeof cancellationonallpolicies thathavean MCS-90or filings.
CertificatesofInsurance
NameMailingAddress
Additional/DesignatedInsuredsforAutoLiabilityorTruckersGeneralLiability
NameMailingAddress*TypeofAdditional Insured
*Pleaseentereachdesiredadditional/designatedinsuredbyenteringthecorrespondingnumber:Auto LiabilityAdditionalInsureds:1.Designated AdditionalInsured,
2.Intermodal,3.AdditionalInsuredWaiverRightsRecovery,4.AdditionalInsuredHired/Non-OwnedGeneralLiabilityAdditionalInsuredsA.ControllingInterest,B.DesignatedPersonorOrganization, C. Managers orLessorsof Premises,D.Mortgagee,E.Owners, LesseesorContractors,F.Co-OwnerofInsured Premises,G. VicariousLiabilityfor Owners, LesseesorContractors
Pleasecompletethissectionfor vehicleswithdifferentownershipor different garagingaddresses
Nameandaddressofvehicle ownersother thanthenamedinsured(ownertypes2,34listedbelow)
UnitNo.Nameof Owner*OwnershipTypeMailingAddress
*Pleaseentertheownertypebyenteringthecorrespondingnumber.1. OwnedbyNamedInsured,2. Owned byLeasingCompany (longterm leasewithoutadriver),
3.OwnedbyOwnerOperator (leasedwithdriver),4. Owned byEmployeeofNamedInsured(officer). Pleasenotethatcoverageforownersmightnotbe affordedifthissectionisnotcompleted.
ForLiabilityCoverage,ifaunitisnotgaragedatthephysicaladdressoftheapplicant, pleaselistthegaragingaddressesforeachunit
UnitNo. / Street Address
City / State / ZipCode / County
UnitNo. / Street Address
City / State / ZipCode / County
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage3of6(9-2009)
CanalTruck Insurance Application
PleasecompletethissectionforAutoPhysicalDamageLoss PayeesUnitNo.Nameof Loss PayeeLoss PayeeCompleteAddress
PleaseListTheNameandAddressofOwnersofNon-OwnedTrailers
Nameof OwnerAddress of Owner
Pleasecompletethissection ifTruckersGeneralLiabilitycoverage isdesired
YesNoDoyouhaulbulk fuel?Ifyes,a$1,000deductibleapplies. If desired, pleaseindicateanoptionalhigherdeductible$ YesNo Doyourepairor servicevehiclesofothers?
YesNoDoyouhavedogsat premises?(seeexclusionendorsement) YesNoDoyou carry afirearm?(seeexclusionendorsement)
YesNoDoyougenerateincomefromotheractivitiesbesides theoperationofthetrucks?
Pleaselist allmobileequipment ownedby theapplicant,ifany (i.e. forklift, backhoe,mobilecrane, etc.)
Pleaselistall premises ownedorrented
Street Address
City / State / ZipCode / County
8.MVRANDCREDITREPORT ACKNOWLEDGEMENT
IauthorizeCanal toobtain a copyofanyMotorVehicleReportfor rating/underwritingtheinsurance forwhichIhaveapplied.Ialsounderstandthata routineinquirymaybemadeprovidinginformationconcerningmycharacter,general reputation,personalcharacteristicsandmodeofliving.Upon writtenrequest, informationas tothenatureandscopeof thereport willbeprovided tome.
Disclosure: Inconnectionwiththisapplicationforcommercialautomobileinsurance,wemayreviewacreditreportorobtainoruseacredit-based insurancescorebasedontheinformationcontainedinthatcreditreport.Wemayuseathirdpartyinconnectionwiththedevelopmentoftheinsurance score.Yourcreditreport/credit-basedinsurancescore willnotbeusedforanypurposeotherthantheunderwritingofthecommercialautomobile insurancepolicyforwhichyouhaveapplied.
Undernocircumstancescanthecredit-basedinsurancescore, the lackthereof,ortherefusaltoauthorizetheobtainingofacreditreportora credit-basedinsurancescorebeafactorindeterminingyoureligibilityfor commercialautomobileinsurance,includingcancellationor nonrenewal, ifapolicyisultimatelyissued.
I authorizeCanaltoobtainacreditreport,includingbutnotlimitedtoacredit-basedinsurancescorebasedon personalinformationprovided.This authorizationisvalidforfuturereportsobtained forrenewalpolicieswithCanal.
Applicant’s SignatureDate
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage4of6(9-2009)
CanalTruck Insurance Application
9.ACKNOWLEDGEMENTANDSIGNATURE
Ihereby certifythat theinformation containedinthis applicationis trueandagree that amisrepresentationof any of thefacts bymewillconstitutereason fortheCompanytovoidorcancelanypolicyissuedonthebasisofthisapplication,andwillholdtheCompanyharmlessfortheactiontaken. Ialso agreethatifapolicyisissuedpursuanttothisapplication,theapplicationandanyelectionsorrejections,whichareincludedwiththeapplicationand signedby me, may berelieduponby theCompany asaccurateand shallbecomeapartofthepolicy. Ifurtherunderstandandagree thattheCompany requiresallunitstobescheduledifI haverequestedanMCS-90orfilings.
Irecognize thatallorpartsof myoperationsareunder theDepartmentofTransportationoversightrequiringme toadheretotheirrulesandregulations. IacknowledgethatDOTrulesandregulationsareunderstoodbyme,andIwilladheretotherulesandregulationsincluding,butnotlimitedto,driver hiring,vehicleinspection,maintenanceandhours of service.
NOTICE:CANAL’SACCEPTANCEOFTHISAPPLICATIONISCONTINGENTUPONTHECONSIDERATIONOF THEAPPLICANT’SCLAIMS HISTORY. IFACCEPTED,YOURCLAIMSHISTORYWILLALSOBECONSIDEREDINDETERMININGIFTHEPOLICYSHOULDBECANCELED ORNON-RENEWED.
MARYLANDFRAUDWARNING
Any personwho knowingly andwillfully presents afalseorfraudulent claim forpayment of alossorbenefit orwho knowingly andwillfully presents false informationinanapplicationforinsuranceis guilty ofacrimeand may be subject tofinesandconfinementinprison.
MARYLANDNOTICEOFUNDERWRITINGPERIOD ADVISORYNOTICETO POLICYHOLDERS
Wearenotifyingyouthatthepolicyyouhavejustagreedtopurchaseissubjecttoa45dayunderwritingperiodbeginningontheeffectivedateofyour coverage.Yourcoveragemaybecancelledduringtheunderwritingperiodifyourriskdoesnotmeetourunderwritingstandards.Ifwedecidetocancel thepolicy,wewillsendyouawrittenNoticeofCancellationadvisingyouofthereason(s)forthecancellationandthedateonwhichyourpolicywillbe cancelled.
SignatureofAPPLICANT X
SignatureofAGENT
Typeor Print ApplicantName
oftheApplicant X
TitleorRelationshiptoApplicantAgency Name
DateandTimeApplicationCompleted Address of Agency
RequestedEffectiveDateandTimeCanalGeneralAgent UseOnly
DateandTimeBound:
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage5of6(9-2009)
CanalTruck Insurance Application
Extra Pagefor AdditionalDriverand VehicleInformation
Drivers,continuedIdeclare thefollowinglist includes alldrivers of vehiclesrequestedtobe coveredunder thepolicy includingemployees, leasedemployees, owner operators, mechanics, familymembers,andany otherpersonallowed todriveaninsuredvehicle.
Driver Name / Yearsof
Experience / ViolationsandMVR Record / DriverLicense
Number / License
State / Year
Hired / Dateof
Birth
DriverswithMultipleViolations
DriverName / ConvictionDateand Violation
Vehicles,continued
DescriptionofVehicles(trailers mustbescheduled forliabilitycoverage toapply whiledetachedfromacoveredpowerunit)
Unit
No. / Model
Year / Makeand UnitType / VehicleIdentification
Number
(VIN) / GVW / Radius / *Stated
Value / Gap Coverage (Y/N) / **Is
Garaging address sameas
physical?
(Y/N)
6
7
8
9
10
11
12
13
14
15
*Onlyapplicableif PhysicalDamage coverageis appliedfor. **Ifaunitisnotgaragedat thephysicaladdress, itisnecessary tolist thegaraging addresses intheAdditional Underwriting Informationsectionof thisapplication.
THISISNOTABINDERTHISISNOTABINDERTHISISNOTABINDER
FormA-101MDPage6of6(9-2009)
CANALMARYLANDSUPPLEMENTALAPPLICATION
INSURANCECOMPANYMUSTbe completedifAuto LiabilityCoverageis requested
INDEMNITY COMPANY
1.ApplicantName
2.DBA,ifany
NOTICE: CANAL’SACCEPTANCEOFTHISAPPLICATION ISCONTINGENTUPONTHECONSIDERATIONOFTHE APPLICANT’SCLAIMSHISTORY. IFACCEPTED,YOURCLAIMSHISTORYWILLALSOBECONSIDERED INDETERMINING IFTHEPOLICYSHOULDBECANCELEDORNON-RENEWED.
MARYLANDFRAUDWARNING
Anyperson whoknowinglyandwillfullypresents afalseorfraudulent claimfor paymentof alossorbenefitor whoknowinglyand willfullypresents falseinformation inan applicationfor insuranceisguiltyof acrimeandmaybesubjecttofines andconfinement in prison.
UNINSUREDMOTORISTSCOVERAGE
UninsuredMotoristsCoverageprovidesprotectionforpersonswhoarelegallyentitledtorecoverdamagesbecauseofbodily injury (includingresultingdeath)ordamagetoproperty fromanowneroroperatorofanuninsuredmotorvehicleorthosewhose liability limitsarelessthanthelimitsofyour UninsuredMotoristsCoverage.
In accordancewithMaryland law,yourcommercial automobile liabilitypolicyautomaticallyincludesUninsuredMotorists Coverage attheFinancialResponsibility Limitsof$75,000bodilyinjury andpropertydamage combinedsinglelimit(CSL);or$30,000each person/$60,000eachaccidentforbodilyinjuryand$15,000eachaccidentforpropertydamageunlessyouselecthigherlimitsof UninsuredMotoristsCoverage. HigherlimitsofUninsuredMotoristsCoveragemaybepurchasedatanadditional premiumprovided thatthelimits selecteddo notexceedthe liability limitsof thepolicy.
Tobe certainthatthepolicy isissuedwiththeUninsuredMotoristsCoveragelimitsthatyouwant, pleaseindicateyourdesired coveragelimitsbelowand signanddatethis form,whereprovided,asyourindication of approval of the limits selected.
I.DISCLOSURE OFUNINSUREDMOTORISTSCOVERAGEPREMIUMS
LimitsOffered / AnnualPremium30/60/15* / 80
75CSL / 144
100CSL / 215
200CSL / 360
250CSL / 430
300CSL / 482
350CSL / 530
400CSL / 578
500CSL / 670
600CSL / 730
750CSL / 790
800CSL / 820
900CSL / 850
1,000CSL / 880
*PropertyDamageUninsuredMotorist Coverage is subjecttoa$250per accidentdeductable.
Applicant’sInitials
THISISNOTABINDERTHISISNOTABINDERTHIS ISNOTABINDERTHISISNOTABINDER
FormA-101MDSUPPPage 1of 4(1-2011)
II. OFFEROFUNINSURED MOTORISTSCOVERAGE
IhavehadthiscoveragefullyexplainedtomeandIwishtopurchaseat UninsuredMotoristsCoverageatthefollowing limits, whichdo notexceedtheLiabilityCoverage limitsofmypolicy(applicableitem marked ):
MinimumRequiredbyLaw(selectonebelow)
BI- $30,000perperson/$60,000per accident;PD- $15,000per accident;or
$75,000combinedsingle limit; or
ThefollowingHIGHERlimit of liability(notto exceedpolicyliabilitylimits)
$__combinedsinglelimit
III. APPLICANT’SACKNOWLEDGMENT
Theundersigner(s)herebyacknowledge(s)they haveread,orhavehadreadtothemandunderstand,theabove explanationsandoffersofUninsuredMotoristCoverage. Selectionshavebeenmade by checkingtheappropriateboxesin SectionII. The signatureappearingbelowisthatofthenamed insuredor authorizationhasbeengiventothesignerofthis Offerof UninsuredMotoristCoveragetoselectorrejectcoverageandlimitsonthebehalf of thenamed insured.
YOUR SELECTIONORREJECTIONOFCOVERAGEIS BINDINGONALLPERSONSINSUREDUNDER THISPOLICY.
Applicant/NamedInsured: / Date:By:
Title:
SignatureofAgentofInsured: Date:
Address:
THISISNOTABINDERTHISISNOTABINDERTHIS ISNOTABINDERTHISISNOTABINDER
FormA-101MDSUPPPage 2of 4(1-2011)
NOTICECONCERNINGTHEWAVIER OFPERSONALINJURYPROTECTION(PIP)COVERAGEIN MARYLAND
Youhave thechoiceofpurchasing certainPersonalInjury Protection(PIP)Coverages. Before decidingwhethertopurchaseor waive this coverage,pleasereadthefollowingcarefully.
FullPIPcoverageprovidesthefollowingprotection,without regardingtofault:
1. Itcoversyouandmembersofyourfamily residingwithyouwhoareinjuredinanymotorvehicleaccident;anyoneinjured while inyour vehicle;andpedestrians injured byyourvehicle.
2. Theminimumcoverageis$2,500andmaybeusedto cover:
a.Allreasonableandnecessarymedicalexpensesincurredwithin3years of injury;and b.85%of actuallyincurredlost wages;or
c.Iftheinjuredpersonisnotemployedatthetimeofinjury,any reasonableandnecessaryexpensestoprovide foressentialserviceswhichthatpersonwouldhaveprovidedforthecareandmaintenanceofhisorher familyorhousehold.
Ifyoudonot signthewaiver,youwillautomaticallyreceivethefull PIPprotectiondescribedabove. YourPIPpremiumwillbe
$annually.
Youmayonlywaive PIPcoveragefor:
1. Thenamedinsured (you);
2. Alllisteddrivers on thepolicy;and
3. Membersofyour familywhoare16years of ageorolder andresidewithyouinyour household.
Thewaiverpreventsthenamedinsured(you)fromcollectingPIPbenefitsunderanymotorvehicleliabilityinsurancepolicy issuedintheStateofMarylandoranotherformofsecurity authorizedto beusedinplaceofamotorvehicleliabilityinsurance policy.
Thewaiverpreventsindividualsdescribedincategory2or3above fromcollectingPIPbenefitsunderyourpolicy. Inaddition,the waiverpreventstheseindividualsfromcollectingbenefitsunder any otherpolicy ofmotorvehicleliabilityinsuranceissuedinthe StateofMarylandoranotherformofsecurityauthorizedto beusedinplaceofamotorvehicleliabilityinsurancepolicy unlessthe individual:
•Isthefirstnamedinsured under theother policy;
•Hasnotwaived PIPbenefitsundertheotherpolicy; and
•Isnotanamedinsured under anypolicyof motor vehicleliability insurancewhereawaiver of PIPbenefits isin effect.
Thewaiverdoesnotimpairthe rightsofother individualssuchaspedestriansorminorchildrenfromcollectingPIPunderyour policy.
Ifyoudecidetosignthewaiver,your PIPpremiumwillbe % of thefull PIPcoverage.Thetotal premiumwillbe
$ annually.
Ifyoudecidenot tosignthewaiver,your insurance companymaynotrefuseto writeyourinsurance coverage.
THISISNOTABINDERTHISISNOTABINDERTHIS ISNOTABINDERTHISISNOTABINDER
FormA-101MDSUPPPage 3of 4(1-2011)
WAIVEROFPERSONALINJURYPROTECTION (PIP)COVERAGE
I hereby confirm thatI have fullyreadand understood theattached notice,requiredby Section19-506 of theInsurance Article,andIunderstandandagreethattheCompany indicatedbelow,inrelianceuponmy signatureasthefirstnamed insured/applicant,willNOTprovide thePersonal InjuryProtection(PIP)coverage requiredbySection19-505and describedintheattachednotice providedtome withthis waiver.Thiscoverageis waivedforanyinjury whichmay be sustainedby:
1. Anyonelistedas anamed insured on thepolicy;
2. All driverslistedon thepolicy; and
3. All membersof thenamed insured’sfamilyliving in theinsured’shousehold whoare16 yearsof age orolder.
Ifurtherunderstand andagree that thewaiverof PersonalInjuryProtection(PIP) benefitsunderthepolicybeingapplied forwaivescoverageforPIPbenefitsforanyone describedaboveunderanyotherpolicyissuedintheStateofMarylandoranotherformof securityauthorized to beused in placeof a motorvehicleliabilityinsurance policy,unless theindividual is:
•Isthefirst named insuredundertheotherpolicy; and
•Hasnot waived PIPbenefitsundertheotherpolicy;and
•Isnot anamed insured underanypolicyof motor vehicleliabilityinsurancewhereawaiverof PIP benefitsisin effect.
I,thefirst named insured/applicant,havefullyreadand understood theabovenoted information and hereby:
(checkone of thefollowing)
request full PIPcoverage be applicableto the policyorbinderofinsurancedescribed below, on allfuturerenewalsof the policyand onall replacement policiesunlessI notifythecompanyinwritingto thecontrary,with theeffectivedate ofsuchchange being no earlierthan thereceipt date bythecompanyof mywrittennotification.
affirmativelywaive the benefits requiredby Section19-505 of the InsuranceArticle (PIP). Iunderstand and agreethat this waiverof coverageshallbeapplicableto thepolicyor binderof insurancedescribed below,on allfuture renewalsof the policyand onall replacement policiesunlessI notifythecompanyinwritingto thecontrary,with theeffectivedateof suchchange being no earlierthan thereceipt date bythecompanyof mywrittennotification.
PrintName:
First NamedApplicant/Insured
Signature:
Signatureof FirstNamed Applicant/Insured
Date: Policy/Binder#:
Insurer:
ProducerName: ProducerCode:
THISISNOTABINDERTHISISNOTABINDERTHIS ISNOTABINDERTHISISNOTABINDER
FormA-101MDSUPPPage 4of 4(1-2011)