EFTA01136396.pdf

COVERAGE SELECTIONS PAGE This page and any attached endorsements form a part of your policy Commerce INSURANCE QA MAteritr COMPANY This policy is issued by: The Commerce Insurance Company Webster, MA 01570-0758 www.Commerceinsurance.com Item 1: This policy is issued to: Massachusetts Personal Automobile Policy Number: DWL496 JOSCHA HACH Agent: 886 W. GOCH I S INS AGENCY, INC MA 02139-2717 113 CAMBRIDGE ST BURLINGTON MA 01803 Item 2: This policy is in effect from: APRIL 28, 2015 to APRIL 28, 2016(12 01 AM Eastern Standard Time) Item 3: Description of your Auto: DIRECT BILL Auto 1 06 HONDA CR-V SE 4D WAGON Auto SHSRD78986U414640 Item 4: This policy provides only the coverages for which a premium charge is shown: Coverages. Parts 1-12 AUTO 1 AUTO Annual Adjusted Annual Adjusted COMPULSORY LIMITS Deduction Premium Premium UMITS Deductible Premium Premium INSURANCE PA None per PencA Person 1 Bodily Injury To Others $ 20000 Pee $ None raw $ 40000 Accident $ 328 328 $ Acc.unt $ $ NONE $ Per Pet 2 Personal Injury Protection $ 8000 Pelson _miner S Person _ snot — Ina s.......d ......... $ 109 109 inennars $ 3 Bodily Injury Caused By An Per PM $ Penal Uninsured Auto (Compulsory $ 100000 PI' None None Pere Limas $20,000 / $40,000) 300000 .<0«,,, $ 24 24 $ ACtAlent $ $ 4 Damage To Someone Else's Pr Peet Property (Compulsory Limits $ None s Academe None $ $5D00) 100000 Acc' 'I $ 425 425 OPTIONAL INSURANCE „. Per Person 5 Optional Bodily Injury To Others $ 100000 None $ PeriCel None Pee PM $ 300000 c ent $ 191 191 $ Aosident $ car Pee 6 Medical Payments $ person None $ $ non None $ 7 Collision Actual Cash Value *$ 1000 $ 458 458 Actual Cash Value $ $ 8 Limited Collision Actual Cash Value $ $ Actual Cash Value $ $ 9 Comprehensive Actual Cash Value $ 300 $ 154 154 Actual Cash Value $ $ Up to $ 15 aday. Uplo$ a day, 10 Substitute Transportation None maximum None $ Z " Tn ) $ 25 25 $ Up to $ for each Up lo $ for each None 11 Towing and Labor None $ disablement disablement $ Per None Pei 12 Bodily Injury Caused By An $ 100000 Pomp° $ PersP" None Underinsured Auto $ 300000 Pe Zee',„,„ s 28 28 S Per Accident $ MERIT RATING PLAN Premium Adjustment $ J Premium Adjustment $ PREMIUM (per AUTO) AUTO $ 1742 1742 1 AUTO s TOTAL PREMIUM (POLICY) * INCL WAIVER OF DED $ 1742.00 -LC - LU1D: Age 65£ Annual Are Good Student DISCOUNTS Account Ceder Mang* TINA Student Ma) StPrt e a MC ZNAa cyCle PU P% S Orm nan er °ea .Ittr rn3n Weac AUTO 1 20% 1% AUTO REFER TO OTHER SIDE FOR ADDITIONAL INFORMATION INSURED PAGE 1 OF 1 12/14 ovals*, 07/18/14 EFTA01136396