The formats contained in this part must be used, but additional information may be included.
Coverage | Premium with no accidents | Premium including surcharge for one chargeable accident | Premium including surcharge for two chargeable accidents |
Bodily injury, property damage | $ 80 | $_____ | $_____ |
Uninsured motorist | $ 5 | $_____ | $_____ |
Personal injury protection | $ 40 | $_____ | $_____ |
Comprehensive | $ 25 | $_____ | $_____ |
Collision | $ 50 | $_____ | $_____ |
Total Premium | $200 | $ | $ |
Coverage | Premium with no accidents | Premium including surcharge for one chargeable accident | Premium including surcharge for two chargeable accidents |
Bodily injury, property damage | $ 80 | $_____ | $_____ |
Uninsured motorist | $ 5 | $_____ | $_____ |
Personal injury protection | $ 40 | $_____ | $_____ |
Comprehensive | $ 25 | $_____ | $_____ |
Collision | $ 50 | $_____ | $_____ |
Total Premium | $200 | $ | $ |
Coverage | Premium with no accidents | Premium including surcharge for one chargeable accident | Premium including surcharge for two chargeable accidents |
Bodily injury, property damage | $120 | $_____ | $_____ |
Uninsured motorist | $ 5 | $_____ | $_____ |
Personal injury protection | $ 60 | $_____ | $_____ |
Comprehensive | $ 40 | $_____ | $_____ |
Collision | $ 75 | $_____ | $_____ |
Total Premium | $300 | $ | $ |
Minn. R. agency 120, ch. 2770, SURCHARGE PLANS AND DISCLOSURE, pt. 2770.1900
Statutory Authority: MS s 65B.133