Creator:
Date Created:
Place Created:
Keywords:May 1, 1974,January 16, 1974
Context:
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AMENDMENT OF DECLARATIONS ENDORSEMENT
Changes- Include Utah No-Fault Endorsements
In consideration of...............................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 :
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 I T	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
0'l	II
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' bil't	$	each person $	each person
y ' y	$_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_
J Utah Personal Injury Protection
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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.....94054.3-QQ.03......issued to H......Tracy Hall,.....Inc............................................
.............................................................................................................................. and underwritten by Amica Mutual Insurance Company and taking effect
on.....January 1, 1974..............................J at ii:0i a.m. I and expiring on.......May 1, 1974.........................................i»t i2:0i a.m./
'	/standard time ^	t ('"" ' —,	/standard timej
Providence, R. I............January 16, 1974............................................................Cj*............Assistant Vice President
F164-7Q 7M 3-73
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