Insurance Policy Example 
 
This is a sample of what your statement might look like. Make sure the two highlighted types of coverage are on your statement. Ask your insurance agent for your own statement.
 
AUTO INSURANCE POLICY DECLARATIONS PAGE
SAMPLE        
         
     

POLICY NUMBER

12345
     

POLICY PERIOD

10/28/05 to 03/31/05
         
     

AGENT:

Mr. Agent
     

PHONE:

516-555-1212
         
MAKE MODEL BODY STYLE VEHICLE ID NUM CLASS
Your Car Your model Sedan ABC-123 auto
         
COVERAGES     PREMIUMS  
See policy for coverage details.        
Bodily Injury/Property Damage liability with supplemental Spousal Liability Insurance*        
      Limits of Liability – Coverage A – Bodily Injury        

 

 		Each Person    Each Accident        

 

 $100,000         $300,000**        

 

 		Limits of Liability – Coverage A – Property Damage        
 

Each Accident

 		       

 

 		$100,000        

 

 		Mandatory Personal Injury Protection   $50,000 $104.25  

 

 		Optional Basic Economic Loss Coverage   $25,000    

 

 		Additional Personal Injury Protection   $100,000 $ 8.46  

 

 		Work Loss Limit per Month (3 year maximum) $4,000      

 

 		Death Benefit $2,000      
  Other Expenses – Limit per Day (1 year maximum) $50      

 

 		Total Personal Injury Protection Benefits   $175,000    

 

 		$500 Deductible Comprehensive and Window Glass     $ 57.29  
  (Deductible does not apply to Window Glass)        

 

 		$1000 Deductible Collision     $120.69  

 

 		Emergency Road Service     $ 1.15  

 

 		Car Rental/Travel Expenses     $ 9.03  

 

 		Each Day    Each Occurrence        

 

 		 80%             $1,000        
Supplementary Uninsured/Underinsured Motorists- SUM     $ 29.25  

 

 		Limit of Liability – Coverage U – Bodily Injury        

 

 		Each Person    Each Accident        

 

 $100,000         $300,000***        

 

 		The maximum amount payable under this coverage shall be the policy’s limits for this coverage reduced and thus offset by Motor Vehicle Bodily Injury Liability insurance policy or bond payments received from, or on behalf of, any negligent party involved in the accident, as specified in the SUM endorsement.        

 

 		Death, Dismemberment, Loss of Sight     $ 1.72  

 

 		Persons Injured – Coverage S - $5,000        

*You must request this- it is IMPORTANT
** These should be increased to at least $300,000 each person and $300,000 each accident, or better $500,000 each.
***These should be increased to at least $300,000 each person and $300,000 each accident, or better $500,000 each.