Personal Injury Protection (PIP) Choice Forms and Bodily Injury Coverage Limits Form __________________________________________

STATE OF MICHIGAN DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES Bulletin 2025-07-INS In the matter of: Personal Injury Protection (PIP) Choice Forms and Bodily Injury Coverage Limits Form __________________________________________/ Issued and entered this 24th day of February 2025 by Anita G. Fox Director This bulletin supersedes Bulletin 2023-11-INS, issued April 13, 2023, to issue a revised version of the Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Form and to reissue the Choice of Bodily Injury Liability Form. Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Forms The Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Form for individuals has been amended for clarity. The new form contains a revised cover page to provide further and more prominent explanation of PIP coverage. The new form also contains an expanded definitions section, which clarifies existing definitions as well as adds definitions for “allowable expenses,” “family-provided attendant care,” and “unlimited PIP medical coverage.” The definition of “Personal Injury Protection (PIP) medical” is removed because the concept is described on the revised form’s cover page. Clarifying changes also have been made to “Section A: Your PIP Medical Choices and the Risks and Benefits of Each,” and “Section D: Certification.” Note that the Section A changes are confined to “Option 1: Unlimited Coverage” and “Option 4: Limited Coverage of $250,000 per person per accident with some or all persons excluded.” The Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Form for commercial policies has also been amended to implement clarifying changes that are consistent with those made in the Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Form for individuals. Automobile insurers must offer applicants and insureds a choice of PIP medical limits for policies issued or renewed after July 1, 2020. Insurers may use the Michigan Selection of Personal Injury Protection (PIP) Medical Coverage Form or their own form. Either way, insurers must file any new or revised form with DIFS for prior approval. In accordance with MCL 500.2236(1), insurers that wish to use a new or revised form must submit their proposed PIP choice form in a form filing no fewer than 30 days prior to the effective date of the form, but in no event later than June 1, 2025. Consumers with a qualified health coverage (“QHC”) are eligible to opt out of purchasing PIP medical coverage pursuant to MCL 500.3107d. Insurers and producers must ensure that consumers who are purchasing or renewing coverage are fully informed of their eligibility to opt out of purchasing PIP medical coverage if they have a QHC deductible that is not greater than the amount determined under MCL 500.3107d(7)(b)(i)(B),which is currently $6,579 or less. See Bulletin 2025-06-INS. Choice of Bodily Injury Liability Coverage Limits Form Section 3009(5) of the Insurance Code, MCL 500.3009(5), requires automobile insurers to use the DIFS Bodily Injury Liability Coverage Limits Form (the “BI Form”). The BI Form has not been amended but is republished here for convenience. Automobile insurers are required to use this form when offering applicants and insureds no-fault automobile insurance that will be issued or renewed after July 1, 2020. The attached BI Form must be offered to all insureds at each renewal after July 1, 2020. Insurers and producers are required to offer, at the time of application or renewal, a list of all bodily injury options that are available from that insurer and the price for each option, not only the $50,000/$100,000 and $250,000/$500,000 limits expressly referenced in the BI Form. Any questions regarding this bulletin should be directed to: Department of Insurance and Financial Services Office of Insurance Rates and Forms P.O. Box 30220 Lansing, Michigan 48909-7720 Toll Free: (877) 999-6442 /s/ ____________________________ Anita G. Fox Director <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 1 of 6 MICHIGAN SELECTION OF PERSONAL INJURY PROTECTION (PIP) MEDICAL COVERAGE -- INDIVIDUALS AGENCY: APPLICANT/NAMED INSURED: INSURANCE COMPANY: POLICY/QUOTE NO.: EFFECTIVE DATE: READ THIS ENTIRE FORM CAREFULLY THE PURPOSE OF THIS FORM The purpose of this form is to explain the choice you have regarding your Personal Injury Protection medical (PIP medical) coverage and to assist you in making that choice. Read this form carefully because the choice you make will have financial consequences. Definitions for all terms in bold type on this form have been provided on the next page. This form is divided into four sections, which are described below. • Section A will review your PIP medical coverage options and the risks and benefits of each option. • Section B will ask you to choose ONE coverage option. • Section C will allow you to identify additional excluded persons not listed in Section B (Option 4 only). • Section D will ask you to certify your choice and acknowledge the information within this form. Personal Injury Protection (PIP) Coverage Explained Personal Injury Protection (PIP) provides coverage for three basic types of benefits: (1) Personal Injury Protection (PIP) medical; (2) wage loss; and (3) replacement services. PIP medical includes allowable expenses for reasonably necessary products, services, and accommodations for an injured person's care, recovery, or rehabilitation. PIP medical includes some funeral and burial expenses. This form allows you to select the level of PIP medical coverage you want included with your auto policy. NOTICE You must choose the level of PIP medical coverage you wish to have under your auto policy. If you do not make a PIP medical coverage selection from the options listed: • Your policy may be issued with unlimited PIP medical coverage; AND • You will be charged the appropriate premium for the coverage issued. If you are renewing an expiring policy that includes a PIP medical coverage selection of unlimited (Option 1), $500,000 per person per accident (Option 2), or $250,000 per person per accident with no excluded persons (Option 3), your policy will be issued with the same PIP medical coverage as your expiring policy. Qualified Health Coverage Proof Requirements All policies with a PIP medical coverage selection of $250,000 with some or all persons excluded (Option 4) OR $50,000 per person per accident (Option 5) OR No PIP medical coverage (Option 6) must provide current updated documentation at issuance and each renewal for Medicaid, Medicare, or other qualified health coverage as applicable to the chosen coverage. If you do not provide the documentation AND: • Your PIP medical coverage selection is $250,000 with some or all persons excluded (Option 4), your policy will be issued with $250,000 PIP medical coverage with no excluded persons (Option 3) and you will be charged the appropriate premium for this coverage. • Your PIP medical coverage selection is $50,000 per person per accident (Option 5) OR no PIP medical coverage (Option 6), your policy will be issued with unlimited PIP medical coverage (Option 1) and you will be charged the appropriate premium for this coverage. Proof of Medicaid coverage may be in the form of a current Medicaid ID card or a letter from the Michigan Department of Health and Human Services. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 2 of 6 Definitions The terms in bold letters throughout this form are defined in this form for informational purposes only and are not intended to limit or expand coverage that may be available in a particular policy. Allowable expenses consist of reasonable charges incurred for reasonably necessary products, services, and accommodations for an injured person's care, recovery, or rehabilitation. Payment of allowable expenses is subject to the terms and limits contained in the insurance policy and the Insurance Code. Allowable expenses include attendant care. Allowable expenses do not include family-provided attendant care for more than 56 hours per week when the insurer has not agreed to pay such benefits in excess of the hourly limitation. This means that prescribed hours in excess of 56 hours per week will be provided by a non-family provider. The Insurance Code does not include the following as allowable expenses: (1) charges for a hospital room that exceed a reasonable and customary charge for semiprivate accommodations, unless the injured person requires special or intensive care; and (2) funeral and burial expenses that exceed the amount set by the policy, which must not be less than $1,750.00 or more than $5,000.00. (3) Insurers also are not required to cover the medical use of marihuana or expenses related to the medical use of marihuana. Applicant means a person who has submitted an application for insurance but is not yet insured under a policy. Attendant care means services that are provided for the particular needs of an injured person, i.e., services that would not have been required before the injury and that are not performed for the benefit of the whole household. • Attendant care generally includes, but is not limited to, serving meals in bed, bathing, dressing, grooming, administering medication, escorting, supervising, or transporting for medical treatment. • Attendant care generally does not include providing transportation that is not for medical treatment, preparing family meals, or maintaining the house, automobile, or yard—even if such tasks would have been performed by the injured person but for the covered injury. • Subject to the dollar limit on the option selected, an injured person is entitled to benefits payable for reasonable charges incurred for as many hours of attendant care as is reasonably necessary for their care, recovery, or rehabilitation. Excess attendant care means additional coverage purchased for attendant care above the PIP medical coverage limit selected for your policy. Family-provided attendant care means attendant care rendered in the injured person's home provided directly, or indirectly through another person, by any of the following: • An individual who is related to the injured person. • An individual who is domiciled in the household of the injured person. • An individual with whom the injured person had a business or social relationship before the injury. Michigan Assigned Claims Plan is a program that may pay benefits to people injured in an accident involving a motor vehicle when there is no applicable automobile insurance policy. Named insured means the individual(s) named in an insurance policy. Qualified health coverage means either of the following: • Health and accident coverage that does not exclude or limit coverage for injuries related to auto accidents and has an annual individual deductible of $6,579 or less; OR • Coverage under both Medicare Parts A and B (or a Medicare Advantage plan). Medicaid and health care sharing ministries are examples of coverages that are NOT considered qualified health coverage. Resident relative means a relative of either you or your spouse who lives in the same household. Unlimited PIP medical coverage (“unlimited coverage”) means PIP medical coverage that has no aggregate dollar limit for payments for allowable expenses related to a covered accident. This coverage is subject to the terms and dollar limits contained in the insurance policy or the Insurance Code. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 3 of 6 Section A: Your PIP Medical Choices and the Risks and Benefits of Each Option 1: Unlimited Coverage This option provides the most coverage. It will pay for all allowable expenses without being subject to an aggregate dollar limit for your care, recovery, and rehabilitation if you are injured in an auto accident. Risks The premiums for this option are higher than premiums for other options. Benefits PIP medical will cover costs that may not be covered by health insurance, such as rehabilitation and attendant care. This choice will significantly limit the risk that you will have out-of-pocket costs for your care. Option 2: Limited Coverage of $500,000 per person per accident or Option 3: Limited Coverage of $250,000 per person per accident If you choose one of these limits, this amount is the most your auto insurance company will pay per person per accident for an injured person’s expenses under PIP medical coverage. NOTE: If you choose Option 2 or Option 3, your insurance company must offer excess attendant care coverage, which you may purchase for an additional premium. Check with your agent or company for additional information. Risks Limited PIP medical coverages may not be enough to cover your medical expenses. If your PIP medical limit is reached, you may need to rely on other health coverage, which may not cover all medical, rehabilitation or attendant care costs. If you do not have other health coverage, you may be personally responsible for paying these expenses. Benefits Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP medical coverage. Up to the limit chosen, PIP medical will cover the cost of products and services that may not be covered by health insurance, such as rehabilitation and attendant care. Option 4: Limited Coverage of $250,000 per person per accident with some or all persons excluded You may select this option if both of the following are true: • A named insured who is excluding PIP medical has qualified health coverage that is not Medicare; AND • Any spouse or resident relative who is excluded from PIP medical has qualified health coverage. Any person who is excluded will have no PIP medical coverage. A person may only be excluded if proof of qualified health coverage has been provided for that person. Any person who is not excluded will be limited to $250,000 in PIP medical coverage, and the named insured will be charged the appropriate premium for this coverage. NOTE: If you choose this option, your insurance company must offer excess attendant care, which you may purchase for an additional premium. This coverage is only available to those who are not excluded from PIP medical coverage. Check with your agent or company for additional information. Risks ANYONE YOU EXCLUDE WILL NOT HAVE PIP MEDICAL COVERAGE. In addition: • Persons relying on qualified health coverage to pay for auto accident injuries should be aware that, unlike auto insurance, health insurance stops paying when the policy ends or is canceled. • If any excluded person loses qualified health coverage, you must notify your insurer within 30 days of loss of coverage. • Within 30 days of losing qualified health coverage, if an excluded person is injured in an auto accident, coverage will be provided by the Michigan Assigned Claims Plan up to $2,000,000 if they have no other qualified health coverage or PIP medical coverage. • A person who has not obtained qualified health coverage or PIP medical coverage within 30 days of the loss of qualified health coverage will not be entitled to any PIP medical benefits. Benefits You will pay a reduced premium because you will not be charged a premium for PIP medical coverage for anyone who is excluded. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 4 of 6 Section A (Continued) Option 5: Limited Coverage of $50,000 per person per accident If you choose this limit, $50,000 is the most your auto insurance company will pay per person per accident for an injured person’s expenses under PIP medical coverage. You may select this option if: • The applicant or named insured is enrolled in Medicaid; AND • Any spouse and all resident relatives have one of the following: a) qualified health coverage; b) coverage under Medicaid, or c) coverage under another Michigan auto policy with PIP medical coverage. NOTES: • Proof of Medicaid coverage may be in the form of a current Medicaid ID card or a letter from the Michigan Department of Health and Human Services. • Your insurance company must offer excess attendant care coverage, which you may purchase for an additional premium. Check with your agent or company for additional information. Risks Limited PIP medical coverages may not be enough to cover the cost of your medical care. If your PIP medical limit is reached, you may need to rely on other health coverage, which may not cover all medical, rehabilitation, or attendant care costs. If you do not have other health coverage, you may be personally responsible for paying these expenses. Benefits Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP medical coverage. Up to the limit chosen, PIP medical will cover the cost of products and services that may not be covered by health insurance, such as rehabilitation and attendant care. Option 6: No PIP medical coverage for anyone covered by this policy You may select this option if: • The applicant or named insured has coverage under both Medicare Parts A and B (or a Medicare Advantage plan), AND • Any spouse and all resident relatives covered by the policy have qualified health coverage or are covered under another auto policy with PIP medical coverage. Risks NO PIP MEDICAL COVERAGE WILL BE PROVIDED UNDER YOUR POLICY. You and any other persons covered by this policy will not have PIP medical coverage. You and those persons may have to rely on other health coverage to pay for medical expenses resulting from an auto accident, which may not cover all products and services that PIP medical provides. • Persons relying on qualified health coverage to pay for auto accident injuries should be aware that, unlike auto insurance, health insurance stops paying when the policy ends or is canceled. • If anyone covered by the policy loses qualified health coverage, you must notify your insurer within 30 days of loss of the coverage. • Within the 30 days of losing qualified health coverage, if anyone covered by the policy is injured in an auto accident, coverage will be provided by the Michigan Assigned Claims Plan up to $2,000,000 if they have no other qualified health coverage or PIP medical coverage. • A person who has not obtained qualified health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP medical benefits. Benefits You will pay a reduced premium because your policy will not be charged a premium for PIP medical coverage. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 5 of 6 (Initial) (Initial) (Initial) (Initial) (Initial) (Initial) Section B: PIP Medical Coverage Options and Certification INITIAL ONE AND ONLY ONE option on the line next to your choice. Make your selection carefully because the choice you make will have financial consequences. If you choose more than one option, your insurer will provide you with the option that has the highest level of benefits and will charge the appropriate premium for that option. ______ Option 1: Unlimited coverage ______ Option 2: $500,000 per person per accident ______ Option 3: $250,000 per person per accident ______ Option 4: $250,000 per person per accident with some or all persons excluded To select Option 4, both of the following must be true and proof must be provided: • A named insured who is excluding PIP medical has qualified health coverage that is not Medicare. • Any resident relative or spouse who is excluded from PIP medical has qualified health coverage. Full Name of Each Excluded Person on the Policy Date of Birth ______ Option 5: $50,000 per person per accident To select Option 5, both of the following must be true and proof must be provided: • The applicant or named insured is enrolled in Medicaid; AND • Any spouse and all resident relatives have qualified health coverage, is enrolled in Medicaid, or are covered under another auto policy with PIP medical coverage. ______ Option 6: No PIP medical coverage. To select Option 6, both of the following must be true and proof must be provided: • The applicant or named insured has coverage under both Medicare Parts A and B (or a Medicare Advantage plan); AND • Any spouse and all resident relatives have qualified health coverage or are covered under another auto policy with PIP medical coverage. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 6 of 6 (Initial) (Initial) (Initial) (Initial) (Initial) Section C: Additional Excluded Persons (Option 4 Only) Full Name of Each Excluded Person on the Policy Date of Birth Section D: Certification You must initial each line and sign and date this form. ______ I have read this form. I understand the PIP medical options available to me and the benefits and risks associated with those options. ______ I have made a PIP medical coverage selection and I understand that the selection I have made binds me and any other person claiming benefits under this policy. ______ I understand that if I don’t make a PIP medical selection in obtaining or renewing a policy, my PIP medical selection will be governed by the terms set forth in the notice box on page 1 and I will be charged accordingly. ______ I understand that if I have chosen Option 4 or Option 6, I must notify my insurer within 30 days if a person who has qualified health coverage loses their qualified health coverage. A person who has not obtained qualified health coverage or PIP medical coverage within 30 days of the loss of coverage will not be entitled to any PIP medical benefits. ______ I understand that if I have chosen Option 4, Option 5, or Option 6, I must provide proof of qualified health coverage at issuance and at each renewal and that failure to do so will result in a change in coverage and I will be charged the appropriate premium for this coverage. APPLICANT/NAMED INSURED SIGNATURE DATE APPLICANT/NAMED INSURED SIGNATURE DATE <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 1 of 3 MICHIGAN SELECTION OF PERSONAL INJURY PROTECTION (PIP) MEDICAL COVERAGE - COMMERCIAL/BUSINESS AGENCY: APPLICANT/NAMED INSURED: INSURANCE COMPANY: POLICY/QUOTE NO.: EFFECTIVE DATE: READ THIS ENTIRE FORM CAREFULLY THE PURPOSE OF THIS FORM The purpose of this form is to explain the choice you have regarding your Personal Injury Protection (PIP) medical coverage and to assist you in making that choice. Read this form carefully because the choice you make will have financial consequences for you, your company, and your employees. Definitions for all terms in bold type on this form have been provided on the next page. This form is divided into three sections, which are described below. • Section A will review your PIP medical coverage options and the risks and benefits of each option. • Section B will ask you to choose ONE coverage option. • Section C will ask you to certify your choice and acknowledge the information within this form. Personal Injury Protection (PIP) Coverage Explained Personal Injury Protection (PIP) provides coverage for three basic types of benefits: (1) Personal Injury Protection (PIP) medical; (2) wage loss; and (3) replacement services. PIP medical includes allowable expenses for reasonably necessary products, services, and accommodations for an injured person's care, recovery, or rehabilitation. PIP medical includes some funeral and burial expenses. This form allows you to select the level of PIP medical coverage you want included with your commercial auto policy. NOTICE You must choose the level of PIP medical coverage you wish to have under your auto policy. If you do not make a PIP medical coverage selection from the options listed: • Your policy may be issued with unlimited PIP medical coverage; AND • You will be charged the appropriate premium for the coverage issued. If you are renewing an expiring policy, your policy will be issued with the same PIP medical coverage as your expiring policy. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 2 of 3 Definitions The terms in bold letters throughout this form are defined in this form for informational purposes only and are not intended to limit or expand coverage that may be available in a particular policy. Allowable expenses consist of reasonable charges incurred for reasonably necessary products, services, and accommodations for an injured person's care, recovery, or rehabilitation. Payment of allowable expenses is subject to the terms and limits contained in the insurance policy or the Insurance Code. Allowable expenses include attendant care. Allowable expenses do not include family-provided attendant care for more than 56 hours per week when the insurer has not agreed to pay such benefits in excess of the hourly limitation. This means that prescribed hours in excess of 56 hours per week will be provided by a non-family provider. The Insurance Code does not include the following as allowable expenses: (1) charges for a hospital room that exceed a reasonable and customary charge for semiprivate accommodations, unless the injured person requires special or intensive care; and (2) funeral and burial expenses that exceed the amount set by the policy, which must not be less than $1,750.00 or more than $5,000.00. (3) Insurers also are not required to cover the medical use of marihuana or expenses related to the medical use of marihuana. Applicant means a person, company, or business who has submitted an application for insurance but is not yet insured under a policy. Attendant care means services that are provided for the particular needs of an injured person, i.e., services that would not have been required before the injury and that are not performed for the benefit of the whole household. • Attendant care generally includes, but is not limited to, serving meals in bed, bathing, dressing, grooming, administering medication, escorting, supervising, or transporting for medical treatment. • Attendant care generally does not include providing transportation that is not for medical treatment, preparing family meals, or maintaining the house, automobile, or yard—even if such tasks would have been performed by the injured person but for the covered injury. • Subject to the dollar limit on the option selected, an injured person is entitled to benefits payable for reasonable charges incurred for as many hours of attendant care as is reasonably necessary for their care, recovery, or rehabilitation. Excess attendant care means additional coverage purchased for attendant care above the PIP medical coverage limit selected for your policy. Family-provided attendant care means attendant care rendered in the injured person's home provided directly, or indirectly through another person, by any of the following: • An individual who is related to the injured person. • An individual who is domiciled in the household of the injured person. • An individual with whom the injured person had a business or social relationship before the injury. Named insured means the individual(s), company, or business named in an insurance policy. Unlimited PIP medical coverage (“unlimited coverage”) means PIP medical coverage that has no aggregate dollar limit for payments for allowable expenses related to a covered accident. This coverage is subject to the terms and limits contained in the insurance policy or the Insurance Code. <INSERT COMPANY FORM NUMBER> Ed. 2025 Page 3 of 3 (Initial) (Initial) (Initial) (Initial) (Initial) (Initial) Section A: Your PIP Medical Choices and the Risks and Benefits of Each Option 1: Unlimited Coverage This option provides the most coverage. It will pay for all allowable expenses without being subject to an aggregate dollar limit for care, recovery, and rehabilitation if a person covered under this policy is injured in an auto accident. Risks The premiums for this option are higher than premiums for other options. Benefits PIP medical will cover costs that may not be covered by health insurance, such as rehabilitation and attendant care. This choice will significantly limit the risk that anyone covered under this policy will have out-of-pocket costs for their care. Option 2: Limited Coverage of $500,000 per person per accident OR Option 3: Limited Coverage of $250,000 per person per accident If you choose one of these limits, this amount is the most your auto insurance company will pay per person per accident for an injured person’s expenses under PIP medical coverage. NOTE: Your insurance company must offer excess attendant care coverage, which you may purchase for an additional premium. Check with your agent or company for additional information. Risks Limited PIP medical coverages may not be enough to cover medical expenses. If the PIP medical limit is reached, an injured person may need to rely on other health coverage, which may not cover all medical, rehabilitation, or attendant care costs. If an injured person does not have other health coverage, they may be personally responsible for paying these expenses. Benefits Lower coverage limits have less expensive premiums than plans with higher or unlimited PIP medical coverage. Up to the limit chosen, PIP medical will cover the cost of products and services that may not be covered by health insurance, such as rehabilitation and attendant care. Section B: PIP Medical Coverage Options and Certification INITIAL ONE AND ONLY ONE option on the line next to your choice. Make your selection carefully because the choice you make will have financial consequences. If you choose more than one option, your insurer will provide the option that has the highest level of benefits and will charge the appropriate premium for that option. ______ Option 1: Unlimited coverage ______ Option 2: $500,000 per person per accident ______ Option 3: $250,000 per person per accident Section C: Certification You must initial each line and sign and date this form. ______ I have read this form. I understand the PIP medical options available and the benefits and risks associated with those options. ______ I have made a coverage selection and I understand that the selection I have made applies to any person claiming benefits under this policy. ______ I understand that if I have not made a selection the policy will either be issued with the same coverages as my expiring policy (if applicable) or unlimited PIP medical coverage and I will be charged the premium for the coverage issued. APPLICANT/NAMED INSURED SIGNATURE DATE <INSERT COMPANY FORM NUMBER> Ed. 7/2/2020 (Initials) (Initials) (Initials) MICHIGAN CHOICE OF BODILY INJURY LIABILITY COVERAGE LIMITS AGENCY: APPLICANT/NAMED INSURED: INSURANCE COMPANY: POLICY/QUOTE NO.: EFFECTIVE DATE: READ THIS ENTIRE FORM CAREFULLY THE PURPOSE OF THIS FORM The purpose of this form is to explain the choice you have regarding your bodily injury liability insurance protection and to assist you in making that choice. Read this form carefully because the choice you make will have financial consequences. PART A: BODILY INJURY LIABILITY INSURANCE COVERAGE EXPLAINED Bodily injury liability insurance covers claims made against you for injuries to others if you are at fault in an auto accident. Michigan auto insurance policies are required to provide bodily injury liability insurance coverage of not less than $250,000 per person and up to $500,000 per accident (“$250,000/$500,000”) for these claims unless you select higher or lower limits depending on the amount of protection you need. In no event can you select less than $50,000 per person and $100,000 per accident. If you do not make a selection, your policy will be issued with limits of $250,000/$500,000. If you want bodily injury liability coverage limits of $250,000/$500,000 or more, you do NOT need to complete this form. PART B: INCREASED RISKS WITH LOWER BODILY INJURY LIABILITY INSURANCE COVERAGE LIMITS If you are responsible for injuries to another person, you may be liable for damages for their pain and suffering, as well as the costs of their medical and other care that exceed their coverage under their auto insurance policy. The bodily injury liability limit of your policy will pay for such damages, but only up to the amount of the limit you choose. You will be required to pay any amount over the limit you choose. This amount could be substantial and may lead to severe financial consequences, such as: • Your assets may be seized, or a lien may be placed on your home; • Your wages may be garnished; or • Your driver’s license may be suspended. Selecting lower bodily injury liability insurance coverage limits may also affect your eligibility for an umbrella policy. PART C: CONFIRMATION OF UNDERSTANDING—YOU MUST READ AND INITIAL EACH LINE _______ I have received a list of all the bodily injury liability coverage options available to me and the price for each option. _______ I understand that any bodily injury liability coverage election I make applies to me and any other person covered by this policy. _______ I understand that the bodily injury liability coverage limits I choose will remain the same as long as the policy is in effect or until I change them. BY SIGNING THIS FORM, I ACKNOWLEDGE THAT: (1) I HAVE READ THIS FORM OR HAD IT READ TO ME; (2) I UNDERSTAND MY CHOICES AND THE POTENTIALLY SEVERE RISKS DESCRIBED ABOVE; AND (3) I AM CHOOSING TO PURCHASE BODILY INJURY LIABILITY COVERAGE LIMITS LOWER THAN $250,000/$500,000. ______________________________________________ ________________ Named Insured/Applicant Signature Date