Insurance PIP Waiver

INSURANCE PIP WAIVER

This Personal Injury Protection (PIP) Waiver documents the insured's election regarding PIP benefits available under the policy identified below. The insured acknowledges that PIP provides coverage for medical expenses, loss of income and related benefits regardless of fault. By completing and signing this Waiver the insured knowingly and voluntarily elects the option(s) indicated below.

Insurer and Policy Identification

Insurer Name:

Policy Number:     Policy Type: Private Passenger Commercial Motorcycle

Policy Effective Date:    Policy Expiration Date:

Applicant / Insured Information

Date of Birth:    Driver's License / ID #:

PIP Coverage Election (select one)

I hereby WAIVE Personal Injury Protection (PIP) benefits in full under the policy identified above. I understand that by electing this option I will not be entitled to PIP medical expense or loss of income benefits for covered persons listed under the policy, subject to applicable law and the terms of the policy.

I ELECT LIMITED PIP benefits. Limit of PIP coverage selected: $ . Any deductible applicable to limited PIP: $ .

I RETAIN full PIP benefits as provided by the policy (no waiver). Selecting this box indicates no waiver is being executed.

Acknowledgements and Important Notices

By selecting any waiver or limitation option and signing below, the insured affirms the following statements (initial each):

Initials: I understand PIP provides no-fault medical and related benefits subject to policy terms and limits.

Initials: I acknowledge this election is made knowingly and voluntarily and is not the result of coercion.

Initials: I understand this waiver may affect the availability of PIP benefits for medical treatment and loss of income arising from covered incidents occurring while the waiver is in effect.

Exclusions and Limitations

The following are examples of matters that may be excluded or limited by this waiver and the policy language. This list is representative, not exhaustive:

- Medical expenses incurred outside the policy period; expenses arising from intentional acts; expenses subject to other coverages or third-party liability. This waiver does not alter liability coverage, uninsured/underinsured motorist coverage, or collision/comprehensive coverages unless expressly stated in the policy.

Beneficiary / Payee for Medical Payments (Optional)

If the insured elects to designate an alternate payee for any medical payment benefits remaining under the policy, complete the following. This designation applies only to payment routing and does not modify coverage terms.

Relationship to Insured:    Percentage of payment to be directed: %

Certification

By signing below I certify that the information provided on this form is true, complete and accurate to the best of my knowledge. I further certify that I have read and understand the election made above and that I am authorized to make this election for all covered persons listed under the policy. I understand that this Waiver will be effective as of the date of signature for incidents occurring on or after the effective date, subject to any additional requirements specified in the policy.

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