<<Agncy_Name:PC>>

ACKNOWLEDGMENT OF COVERAGE REQUESTED


Dated: <<Today>>, I, <<Cli_First>> <<Cli_Last>> , (applicant) Binder/Policy Number <<Pol_PolNum>>, understand that I have applied for only those coverages indicated by my initials and that no other coverages have been requested, represented or are expected to apply in this transaction


_____________________________________________________________________

COVERAGE REQUESTED EFFECTIVE DATE: <<Pol_EffectDate>>

=====================================================================


<<Coverage Summary List:Colors=#000000|#FFFFFF:IncDed=True:IncPremium=True>>


<<Vehicle List>>


☐ ACCEPTED ☐ DECLINED: Rental

[Not available without Collision & Comprehensive coverages, not offered by all insurance carriers]


☐ ACCEPTED ☐ DECLINED: Towing

[Not available without Collision & Comprehensive coverages, not offered by all insurance carriers]


☐ ACCEPTED ☐ DECLINED: Motorist Protection Policy (MPP) [Includes towing for mechanical breakdown coverage up to specified miles and number of tow calls per year.]


☐ Yes ☐ No Special Equipment Coverage: [Not available without Collision & Comprehensive coverages, not offered by all insurance carriers]


If yes, then list items for each vehicle and name the vehicle:

_____________________________________________________________________


_____________________________________________________________________


_____________________________________________________________________

　　


===============================================

All Vehicles:


===============================================

☐ ACCEPTED: Liability


<<Auto_Bi>>


<<Auto_Pd>> Property Damage per Occurence

☐ DECLINED: Liability


===============================================

☐ ACCEPTED: Excess Medical Payments Up to <<Auto_Med>>


☐ DECLINED: Excess Medical Payments


===============================================

☐ ACCEPTED: UMBI -Uninsured Motorist Bodily Injury <<Auto_Uimbi>>


☐ ACCEPTED: UMPD/CDW -

$3,500 Uninsured Motorist Property Damage or Collision Deductible Waiver


☐ DECLINED: ALL UM-BI, UM-PD or UM-CDW


Uninsured Motorist Bodily Injury


$3,500 Uninsured Motorist Property Damage or Collision Deductible Waiver


===============================================


　


Signature of Applicant: _______________________________ Date: _____________