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619 views4 pages

Declaration Page

Uploaded by

manassendombasi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Tel: 1-800-841-3000 Declarations Page

This is a description of your coverage.


Please retain for your records.
GEICO General Insurance Company
One GEICO Boulevard Policy Number: 6177-09-41-71
Fredericksburg, VA 22412-0003
Coverage Period:
09-17-24 through 03-17-25
12:01 a.m. local time at the address of the named insured.

Endorsement Effective: 09-19-24


Date Issued: September 20, 2024

MANASSE N WADI
4803 NORSTAR BLVD APT 322
LIVERPOOL NY 13088-4240

Email Address: [email protected]

Named Insured Additional Drivers


Manasse N Wadi None

Vehicle VIN Vehicle Location Finance Company/


Lienholder
1 2015 Kia Optima 5XXGN4A78FG446827 LIVERPOOL NY 13088-4240 kellogg community cu

+Supplemental Spousal Liability (SSL) insurance provides bodily injury liability coverage under this policy
when a person is injured or killed in a motor vehicle accident caused by the negligence of the person’s spouse.
You currently do not carry SSL, so no additional premium was charged, and SSL will not apply under this
policy. To ensure SSL will not be added to this policy, resulting in a change to your premium, please submit a
completed M316NYC form if you have not already done so. SSL can be added for $19.90 for the vehicle(s) listed
on your policy; however, it will not increase the limit of the coverage. If you would like to add SSL, please visit
geico.com.

++ Supplementary Uninsured/Underinsured Motorists Coverage includes out-of-state Uninsured/Underinsured Motorist


Coverage. The maximum amount payable under SUM Coverage shall be the policy's SUM limits 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.

Coverages* Limits and/or Deductibles Vehicle 1

Bodily Injury Liability +


Each Person/Each Occurrence $100,000/$300,000 $138.50
Property Damage Liability $100,000 $200.40
Basic Personal Injury Protection
Please Refer To The New York No-Fault
Benefits Section Opt-A/50,000/2,000 W/L $62.60

Tier H
Continued on Back
DEC_PAGE (11-11) (Page 1 of 4) Endorsement Page 3 of 7
Coverages* Limits and/or Deductibles Vehicle 1

Supplementary Uninsured/
Underinsured Motorists (SUM) ++
Each Person/Each Occurrence $100,000/$300,000 $42.70
Comprehensive (Excluding Collision) $500 Ded/Full Glass $80.40
Collision $500 Ded $279.10
Emergency Road Service Full $15.40
Rental Reimbursement $50 Per Day
$1,500 Max $30.60

Total Six Month Premium $849.70

*Coverage applies where a premium or $0.00 is shown for a vehicle.

If you elect to pay your premium in installments, you shall be subject to an additional fee for each installment. The fee amount
will be shown on your billing statements and is subject to change.

New York No-Fault Benefits Section


Below is a breakdown of your No-Fault (PIP) coverages to show how much No-Fault coverage you have and the
premium. The premiums shown below are already included in your 6 month premium. Your total premium is shown in
the coverage section. Your No-Fault coverages with premiums and your other coverages and premiums are shown in
the Coverage section. REFER TO THE COVERAGE SECTION AND THE PERSONAL INJURY PROTECTION
AMENDMENT FOR THE OPTION YOU CARRY.

Coverage Limit and Deductibles Vehicle 1

Basic Personal Injury Protection $50,000.00 $62.60


Total $62.60
Aggregate No-Fault Benefits Available $50,000.00
NON Ded

**Maximum Monthly Work Loss Benefit $2,000.00


Other Necessary Expenses Per Day $25.00
Death Benefit $2,000.00

** THE MAXIMUM MONTHLY WORK LOSS BENEFIT AND OTHER NECESSARY EXPENSES PER DAY ARE
INCLUDED IN THE AGGREGATE SHOWN ABOVE. THE $2,000 DEATH BENEFIT IS IN ADDITION TO THE
AGGREGATE.

Continued on Next Page


DEC_PAGE (11-11) (Page 2 of 4) Endorsement Page 4 of 7
Discounts and Premium Reductions Vehicle 1
The total value of your discounts and premium reductions is $177.30
Anti-Lock Brakes $49.40
Passive Restraint/Air Bag $24.50
Anti-Theft Device $8.60
5 Year Good Driving $94.80
Total $177.30

The Reductions shown above are already reflected in your six month premium.

Contract Type: FAMILY

Contract Amendments: ALL VEHICLES - A30NY(04-20) A54NYA(05-23) SIGPGCW(07-20)

Unit Endorsements: UE316E(02-16) (VEH 1); A331(04-20) (VEH 1); M489NY(09-21) (VEH 1); A115S(08-20)
(VEH 1); A431NY(04-20) (VEH 1)

Class, Symbols and Vehicle Liability Symbol: A -M -30-49 -L 26 29 P(VEH 1)

Important Policy Information


- Reminder - Physical damage coverage will not cover loss for custom options on an owned automobile, including
equipment, furnishings or finishings including paint, if the existence of those options has not been previously reported
to us. This reminder does NOT apply in VIRGINIA, however, in Virginia coverage is limited for custom furnishings or
equipment on pick-up trucks and vans but you may purchase coverage for this equipment. Please call us at
1-800-841-3000 or visit us at geico.com if you have any questions.
- If we cancel your policy due to nonpayment of premium or for underwriting reasons and your coverage lapses, we will
assess a $35.00 fee to reissue your policy. We will not reissue the policy (and you will not have coverage) if the fee is
not paid.
- Your rate is partly determined by factors including your credit based insurance score, driving activity, and vehicle
usage. If you think any of these characteristics have recently changed, please contact us at 1-866-319-8690 for a
policy review.
- If your payment is dishonored by your bank or financial institution, GEICO will assess a $20.00 service fee to your
account to cover the additional time and expense we incur to collect your premiums.

DEC_PAGE (11-11) (Page 3 of 4) Endorsement Page 5 of 7


DEC_PAGE (11-11) (Page 4 of 4) Endorsement Page 6 of 7

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