Commercial Automobile

Application Supplement

Maryland

(To be completed and signed by the Named Insured)

Name / Policy Number

For More Detailed Description of These Coverages, Refer To Your Policy

Uninsured Motorists Coverage

Uninsured Motorists insurance provides protection against owners or operators of uninsured motor vehicles. A motor vehicle is uninsured if:

  1. There is no liability insurance or other security applicable to the motor vehicle to pay for damages sustained by others because of an accident; or
  2. There is liability insurance or other security applicable to the motor vehicle to pay for such damages but the amount available is less than your uninsured motorists coverage; or
  3. It is a hit and run vehicle and the owner or operator cannot be identified.

Property damage coverage is subject to a $250 deductible.

Maryland law gives you the right to select Uninsured Motorists Bodily Injury and Property Damage coverage at a limit higher than the minimum limit required by law ($55,000 CSL), but not higher than your policy’s limit of liability. Please indicate your choice by checking the appropriate box below:

I want to select Uninsured Motorists Bodily Injury and Property Damage at the limit equal to my policy’s limit for bodily injury and property damage liability.
I want to select Uninsured Motorists Bodily Injury and Property Damage coverage at a limit lower than my policy’s limit for bodily injury and probperty damage liability (but not lower than $55,000 as required by law). I understand I am rejecting the increased limits coverage. I want the coverage at a limit of $ .

I understand that I have the right to purchase Uninsured Motorists Bodily Injury and Property Damage coverage with limits higher than $55,000 CSL. I have indicated my selection of coverage above.

I understand that my coverage selection or rejection shall apply on this policy and all future renewals, until I notify the Northland Insurance Company IN WRITING of any changes.

Signature of Named Insured / Date
Signature of Agent / Date

(Refer to other side.)

Important Notice Concerning the Waiver of Personal Injury Protection (PIP) Under Commercial Automobile Liability Insurance

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Beginning July 1, 1989, you have the choice whether to purchase certain personal injury protection (PIP) coverages, which were formerly required by Maryland law. Before deciding whether to purchase or waive this coverage, please read the following carefully.

If you do not waive PIP, your premium for the full PIP coverage will be $. If you choose to affirmatively waive PIP, your premium for partial PIP coverage will be % of the full PIP coverage, or $. Full PIP coverage provides the following protection without regard to fault:

  1. It covers individuals injured in an automobile accident in which your covered vehicle is involved; and individuals injured while getting into or out of your covered vehicle; and
  2. It provides minimum coverage of $2,500, and may be used to cover:
  1. Reasonable and necessary medical expenses incurred within 3 years; and
  2. 85% of actually incurred lost wages; or
  3. If the injured person is not employed at the time of injury and reasonable and necessary expenses to provide for essential services which that person would have provided for the care and maintenance of his or here family or household.

If you do not sign the waiver, you will automatically receive the full PIP protection described above.

The waiver prevents the following individuals from collecting any PIP benefits under the provisions of this policy:

  1. Anyone listed as a named insured on the policy;
  2. All listed drivers on the policy; and
  3. Any individual operating or occupying the vehicle within the scope of his or her employment.

Under the provisions of the waiver none of the individuals listed above are entitled to PIP coverage under the policy to which the waiver is attached. It does NOT impair the rights of other individuals, such as pedestrians or commercial passengers from collecting PIP under your policy. Should you fail to properly waive PIP coverage all benefits outlined under full PIP coverage will be provided under the policy.

In order to waive the PIP benefits, you must sign an affirmative waiver form and submit it to your insurance company. If you decide not to sign the waiver, the insurance company cannot refuse to write your insurance coverage and must provide all coverages and benefits described above, and in section 19-505 of the insurance article.

Waiver of Personal Injury Protection (PIP) Coverage Commercial Automobile Liability Insurance

I hereby affirm that I have fully read and understood the attached notice, required by section 19-506(c) of the insurance article, and it is hereby understood and agreed that Northland Insurance Company in reliance upon my signature as the first named insured/applicant, will not provide the Personal Injury Protection (PIP) coverage benefits under this Northland policy, required by section 19-505 and described in the attached notice provided to me with this waiver. This coverage is waived for any injury which may be sustained by:

  1. Anyone listed as a named insured on the policy;
  2. All drivers listed on the policy; and
  3. Any individual operating or occupying the vehicle within the scope of his or her employment.

It is further understood and agreed that the waiver of Personal Injury Protection (PIP) benefits under policy/binder # waives coverage for PIP benefits only under this policy.

I affirmatively waive the benefits required by section 19-505 of the insurance article. I understand and agree that this waiver of coverage shall be applicable to the policy or binder of insurance described below, unless I notify the company in writing to the contrary, with the effective date of such change being no earlier than he receipt date by the company of my written notification.

Date: / Policy/Binder Number:
Agent/Producer Code:
Agent/Producer Name:
Signature of First Named Applicant/Insured/Corporate Representative:
Title:
Company Name:

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