Commercial Consumer Information And Coverage Selection Form (Page 4 of 5) in pdf

Medical Payments, Collision, and Comprehensive Coverages --Optional Coverages

Medical Payments Coverage

It’s your choice whether to buy medical payments coverage. This coverage pays for reasonable medical, hospital or

limited funeral expenses for you or others injured or killed while driving or riding in your vehicle even if you are legally

responsible for the accident. The payment of benefits under this coverage could be affected by Arizona’s workers’

compensation laws.

Medical Payments Coverage Selection. Initial your selection below. Please Note: Read your policy to learn the

specifics about what medical payments coverage includes and what it doesn’t include.

____

I select medical payments coverage with the following limit:

$________________.

____

I select medical payments coverage with different limits for each of my vehicles as shown on my application.

____

Not offered by this insurer. You may buy this coverage from another insurer.

____

I reject medical payments coverage.

Collision Coverage

State law does not require you to buy collision coverage. But if you leased or borrowed money to buy your vehicle,

you may be required to buy this coverage.

Collision coverage pays to repair, replace or reimburse you for property damage to your insured vehicle. It pays for

damage caused by a collision (an impact) with another motor vehicle or with any other object, movable or fixed, including

damages caused if your vehicle overturns. Collision pays for damages to your vehicle, even if an uninsured motorist or an

underinsured motorist hits you or if you are responsible for the collision.

You may buy collision coverage with a deductible option. Your deductible will be the amount you agree to pay from

your own pocket before your insurer will pay for any damage. You may also buy collision coverage with different deductible

amounts for each vehicle covered by your policy.

To decide if you should buy collision coverage, consider the value of your vehicle. Also think about how you would

pay to repair your vehicle if you don’t buy this coverage.

Collision Coverage Selection. Initial your selection below. Please Note: Read your policy to learn the specifics

about what collision coverage includes and what it doesn’t include.

____

I select collision coverage with the following deductible for all vehicles insured by my policy:

$________________.

____

I select collision coverage with different deductibles for each of my vehicles as shown on my application.

____

Not offered by this insurer. You may buy this coverage from another insurer.

____

I reject collision coverage.

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This page has been corrected as noted in Circular Letter 1997-8

Commercial Consumer Information And Coverage Selection Form Page 4