| This is a sample of what your statement might look like. Make sure the two highlighted types of coverage are on your statement. Ask your insurance agent for your own statement. |
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| AUTO INSURANCE POLICY DECLARATIONS PAGE |
| SAMPLE |
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POLICY NUMBER |
12345 |
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POLICY PERIOD |
10/28/05 to 03/31/05 |
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AGENT: |
Mr. Agent |
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PHONE: |
516-555-1212 |
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| MAKE |
MODEL |
BODY STYLE |
VEHICLE ID NUM |
CLASS |
| Your Car |
Your model |
Sedan |
ABC-123 |
auto |
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| COVERAGES |
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PREMIUMS |
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| See policy for coverage details. |
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| Bodily Injury/Property Damage liability with supplemental Spousal Liability Insurance* |
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Limits of Liability – Coverage A – Bodily Injury |
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Each Person Each Accident |
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$100,000 $300,000** |
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Limits of Liability – Coverage A – Property Damage |
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Each Accident |
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$100,000 |
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Mandatory Personal Injury Protection |
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$50,000 |
$104.25 |
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Optional Basic Economic Loss Coverage |
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$25,000 |
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Additional Personal Injury Protection |
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$100,000 |
$ 8.46 |
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Work Loss Limit per Month (3 year maximum) |
$4,000 |
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Death Benefit |
$2,000 |
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Other Expenses – Limit per Day (1 year maximum) |
$50 |
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Total Personal Injury Protection Benefits |
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$175,000 |
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$500 Deductible Comprehensive and Window Glass |
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$ 57.29 |
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(Deductible does not apply to Window Glass) |
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$1000 Deductible Collision |
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$120.69 |
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Emergency Road Service |
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$ 1.15 |
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Car Rental/Travel Expenses |
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$ 9.03 |
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Each Day Each Occurrence |
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80% $1,000 |
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| Supplementary Uninsured/Underinsured Motorists- SUM |
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$ 29.25 |
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Limit of Liability – Coverage U – Bodily Injury |
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Each Person Each Accident |
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$100,000 $300,000*** |
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The maximum amount payable under this coverage shall be the policy’s limits for this coverage reduced and thus offset by Motor Vehicle Bodily Injury Liability insurance policy or bond payments received from, or on behalf of, any negligent party involved in the accident, as specified in the SUM endorsement. |
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Death, Dismemberment, Loss of Sight |
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$ 1.72 |
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Persons Injured – Coverage S - $5,000 |
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