Creator:
Date Created:
Place Created:
Keywords:AMICA INSURANCE,February 7, 1974,February 14, 1974
Context:
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AMICA
INSURANCE
February 7, 1974
February 14, 1974
AMENDMENT OF DECLARATIONS ENDORSEMENT
Changes■Araend Utah Personal Injury Protection
In consideration ofsn additional..........premium of $..................., it is agreed that the policy declarations are amended as
follows:
Name of insured
Address of insured
County
The automobile will be principally garaged in the above town or city, unless otherwise stated herein:
County
AUTOMOBILE ADDED
It is agreed that this policy shall apply to the automobile described below:
Qar t
Year of Model	Trade Name; Number of Cylinders; Body Type	Model Identification, Serial or Motor Number
The automobile is unencumbered unless otherwise stated herein: Purchased (Month, Year) New or Used F.O.B. List Price Actual Cost ~ ~	Installment Payments	Due Date and Amount
_____incumbrance Number Amount of Each	of Final Installment
_ _ $__$__$_
Loss Payee: Any loss under coverages D and E is payable as interest may appear to the named insured and...................................................................................................
Use: The purposes for which the automobile added is to be used are "pleasure and business," unless otherwise stated herein:..............................................
AUTOMOBILE ELIMINATED It is agreed that this policy does not apply to the automobile described below:
Year of Model Trade Name; Number of Cylinders; Body Type Model Identification, Serial or Motor Number ___
It is agreed that the COVERAGES and LIMITS OF LIABILITY are changed to read as follows:_
LIMITS OF LIABILITY LIMITS OF LIABILITY COVERAGES__CAR NO.___CAR NO._
A B d'l I ' L' b i t	®	each person $	each person
J	_$_each accident $_each accident
B Property Damage Liability__$___each accident $_each accident
C Medical Payments__$_each person__$_each person
D Collision or Upset__Actual Cash Value less $_deductible Actual Cash Value less $_deductible
E Comprehensive- Excluding Collision or Upset
F Towing and Labor Costs	$	for each disablement _$_for each disablement
RATE CLASSIFICATIONS
__B.I.-P.D._Collision_| B.I.-P.D._Collision_
[2 Utah Personal Injury Protection-
§ Utah Out nf Sf.afp Eyfpnsinn_
| Utah Additional Personal Tnjury Protection A—$12,000 B-S250_
o-
z_
Nothing contained herein shall be held to vary, waive, alter, or extend any of the terms, conditions, agreements, or declarations of the policy to which this endorsement is attached, other than as stated above.
Attached to and forming part of Policy No. 94 054.3-0.0 03........issued to .ft......Tra.C.y .Hall,.....Inc.,.............................................
..........................................................................................i....................................and underwritten by Amica Mutual Insurance Company and taking effect
on January. 1,.....1974................................J at 12:01 A.M. I a„d expiring on May.....1,......19.74...............................................H 12:01 A;M.{
/standard time}	.	/standard time}
Providence, R. I. February. .1.,......19 7.4..............................................................................(J ".................^^.^L^^rAssistant Vice President
f164-7q 7m 10-73	^
0
E031
OUT-OF-STATE EXTENSION OF PERSONAL INJURY PROTECTION
UTAH
The Company agrees with the named insured, subject to all of the provisions of the Personal Injury Protection Endorsement (Utah) and to all of the provisions of the policy except as modified herein, as follows: The Company will pay personal injury protection benefits for
(a)	medical expenses,
(b)	work loss,
(c)	funeral expenses, and
(d)	survivor loss
with respect to bodily injury sustained by an eligible injured person who is a named insured or relative, caused by an accident involving the use of a motor vehicle as a motor vehicle.
Exclusions
Exclusions e, f, g, and h of the Personal Injury Protection Endorsement (Utah) apply to the coverage provided under this endorsement, and the coverage under this endorsement does not apply:
(a)	to bodily injury sustained by any person through the use of a motor vehicle which is owned by the named insured and which is not an insured motor vehicle;
(b)	to bodily injury sustained by any person, other than the named insured, through the use of a motor vehicle owned by such person, with respect to which Out-of-State Extension of Personal Injury Protection Coverage is not in effect;
(c)	to bodily injury sustained by any person while occupying any motor vehicle without the express or implied consent of the owner of such motor vehicle or while not in lawful possession of such motor vehicle.
Definitions
The definitions contained in the Personal Injury Protection Endorsement (Utah) apply to the coverage provided under this endorsement, except that the definitions of "insured motor vehicle" and "motor vehicle" are replaced by the following: "insured motor vehicle" means a motor vehicle with respect to which
(a)	the bodily injury liability insurance of the policy and the insurance provided under this endorsement for which a specific premium is charged apply, and
(b)	the named insured is required to maintain security under the provisions of the Utah Automobile No-Fault Insurance Act; "motor vehicle" means any vehicle of a kind required to be registered with the Division of Motor Vehicles of the Utah State Tax Commission under Title 41-1-19, Utah Code Annotated 1953 but excluding motorcycles; regardless of whether such vehicle is registered in any state.
Policy Period; Territory
This coverage applies only to accidents which occur during the policy period and within the United States of America, its territories, possessions or Canada, except that this coverage does not apply to accidents which occur within the State of Utah.
The Limits of Liability provision, the Conditions and Sections II and III of the Personal Injury Protection Endorsement (Utah) apply to the coverage provided under this endorsement.
E032
ADDITIONAL PERSONAL INJURY PROTECTION — INCREASED LIMITS
UTAH
It is agreed that the Personal Injury Protection Endorsement (Utah) is amended as follows, but only with respect to any amounts payable thereunder because of bodily injury to an eligible injured person who is a named insured or relative;
1.	The Limits of Liability provision of the Personal Injury Protection Endorsement (Utah) is amended by substituting the amounts set forth in the Schedule as follows:
(a)	paragraph 1. is amended by substituting the amount shown opposite A for the amount of $2,000;
(b)	paragraph 2(a) is amended by substituting the amount shown opposite B for the amount of $150.
2.	This endorsement is subject to all the terms of the Personal Injury Protection Endorsement (Utah) not expressly modified herein.
SCHEDULE
Maximum Amount
A.	Medical Expenses	$ See Declarations
Maximum Weekly Limit
B.	Loss of Gross Income and Earning Capacity	$ See Declarations
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Amica Mutual Insurance Company
> Assistant Vice President
F731-2 300 12-73 U \\ k_