· $50 for locksmith assistance if you are locked out of your insured vehicle, providing the...

ANA0001D MA-0316 © American International Group, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,

with its permission.

New Hampshire Insurance Company

[A Stock Company]

Policy Declarations Page - MASSACHUSETTS Producer

Policy Number State Agent Number Policy Period Transaction Declaration # Amended Date

Named Insured

This Declarations Page with policy provisions completes this policy.

Collector Vehicles

# Year Make Body Model Identification # Agreed Value Mileage Tier

Selected Coverages

Coverage is provided where a Premium and Limit of Liability are shown for the Coverage

Coverage (Limit) Vehicle

Vehicle Premium

Endorsements Made A Part Of This Policy Annual Premium

Alternate Addresses

Excluded Drivers

AB3861EPC-0316 © American International Group, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,


INCREASED LIMITS FOR SPARE PARTS COVERAGE ENDORSEMENT MASSACHUSETTS

In return for additional premium, this endorsement amends the Antique Auto Coverage Endorsement Massachusetts. Section III – PART D – COVERAGE FOR DAMAGE TO YOUR AUTO – SPARE PARTS COVERAGE is deleted and replaced with: SPARE PARTS COVERAGE

Spare parts are additional parts that you own for “your covered auto”. We will pay up to the limit of liability shown on the Declarations page for direct and accidental loss to spare parts and accessories to “your covered auto”. However, we will pay for loss covered by collision or other than collision coverages only if the Declarations indicate that such coverage is afforded.

We do not cover: 1. Parts and accessories held for sale by you; or 2. The property of others in your care, custody and control.

ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN THE SAME.

New Hampshire Insurance Company A STOCK INSURANCE COMPANY

A STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY INCORPORATED UNDER THE LAWS OF ILLINOIS

READ YOUR POLICY CAREFULLY

ANTIQUE & COLLECTIBLE VEHICLE POLICY MASSACHUSETTS

In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative.

THIS POLICY JACKET TOGETHER WITH THE PERSONAL AUTO POLICY, DECLARATIONS AND ENDORSEMENTS, IF

ANY, ISSUED TO FORM A PART THEREOF, COMPLETES THIS POLICY.

Secretary President

AJ9898JPC MA-0316 © American International Group, Inc. All rights reserved.Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Page 1 of 1

{ {{ {

A1028APC-0316 © American International Group, Inc. All rights reserved. Page 1 of 1

Includes copyrighted material of Insurance Services Office, Inc., with its permission.

UNINSURED/UNDERINSURED MOTORISTS SELECTION/REJECTION FORM

MASSACHUSETTS

IMPORTANT – PLEASE READ AND SIGN BELOW

UNINSURED MOTORISTS COVERAGE

Uninsured Motorist (UM) coverage pays you for damages due to bodily injury, sickness, disease or death you would be entitled to recover from the owner or operator of a hit and run or uninsured motor vehicle. Massachusetts requires your policy to include mandatory limits of Uninsured Motorist coverage of $20,000/$40,000 however, you may elect Uninsured Motorist coverage up to the maximum of your liability limit. YOUR REGULAR FAMILY CARS MUST HAVE AT LEAST AS MUCH UNINSURED MOTORIST COVERAGE AS YOU ARE REQUESTING FROM US.

I have read this statement and hereby:

Elect Uninsured Motorist Coverage limits of: [ $20,000/$40,000] [ $50,000/$100,000] [ $100,000/$100,000] [ $100,000/$300,000] [ $300,000/$300,000] [ $250,000/$500,000] [ $300,000/$500,000] [ $500,000/$500,000]

UNDERINSURED MOTORISTS COVERAGE

Underinsured Motorist (UIM) coverage pays you for damages due to bodily injury, sickness, disease or death you would be entitled to recover from the owner or operator of an underinsured motor vehicle. Underinsured Motorist coverage is an optional coverage. You may elect Underinsured Motorist coverage up to the maximum of your liability limit or you may reject Underinsured coverage entirely. YOUR REGULAR FAMILY CARS MUST HAVE AT LEAST AS MUCH UNDERINSURED MOTORIST COVERAGE AS YOU ARE REQUESTING FROM US.


Elect Underinsured Motorist Coverage limits of:

[ $20,000/$40,000] [ $50,000/$100,000] [ $100,000/$100,000] [ $100,000/$300,000] [ $300,000/$300,000] [ $250,000/$500,000] [ $300,000/$500,000] [ $500,000/$500,000]

Reject Underinsured Motorist coverage entirely I have read and understand the contents of this notice regarding Uninsured/Underinsured Motorists Coverage. I understand and agree that this coverage election applies to my Antique Automobile Policy and future renewals until I advise the Company or its authorized representative, in writing, to the contrary.

SIGNATURE OF NAMED INSURED

X DATE

/ /

AB1106EPC-0316 © American International Group, Inc. All rights reserved. Page 1 of 4


TOWING AND LABOR EMERGENCY EXPENSE REIMBURSEMENT MASSACHUSETTS

This Endorsement is designed for the insured whose collector vehicle has an emergency condition and should not be construed as a repair or maintenance service. It reimburses you for the expenses described when an emergency condition occurs to a covered auto.

In return for an additional premium, we will provide the coverage: (1) for the Plan indicated on the Declarations Page; and (2) to the vehicle(s) listed on the Declarations Page.

SILVER PLAN

The following coverages apply to this plan and are subject to the exclusions shown in Section V.

I. $100 Emergency Towing: You will be reimbursed up to a maximum of $100 per disablement if your vehicle does not start or will not operate under its own power without causing damage. You will need to contact the facility of your choice and submit a claim to us for reimbursement. Emergency Towing Service covers a maximum of 3 breakdowns per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

II. $50 Roadside Assistance: You will be reimbursed up to a maximum of $50 per disablement if your vehicle is disabled and unable to be driven under its own power as defined below. You will need to contact the facility of your choice and submit a claim to us for reimbursement. Emergency Roadside Assistance covers a maximum of 3 breakdowns per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

Vehicle does not start: Minor emergency mechanical adjustments and battery boost at the point of disablement.

Flat Tire: Service call to repair your tire or install your inflated spare. (If you have no spare or if your spare is flat, no reimbursement is available for the cost of a replacement tire.)

Stuck: Service to extricate your vehicle from a ditch, snow, mud, or sand. (Cannot be used for everyday snow removal.)

In need of liquids or parts: Service to deliver an emergency supply of gas, oil or water, or other materials or parts needed to get your vehicle back on the road.

III. $50 Emergency Lockout: You will be reimbursed up to

$50 for locksmith assistance if you are locked out of your insured vehicle, providing the following conditions apply:

1. An itemized receipt or statement from a commercial locksmith service or other service facility, detailing the amount charged for lockout service must be included when filing an Emergency Lockout Claim.

2. You must be with your vehicle at time of lockout. 3. Private citizen’s assistance is not reimbursable. IV. Lost Key: When you purchase this coverage you will be

provided with a registered numbered key ring card. If your key is lost, return postage is guaranteed and paid by us

when placed in the U.S. mail. Upon receipt of the lost key, we will contact you and return your key.

V. Exclusions:

1. Disablement which occurs to vehicles not listed on the Declarations Page;

2. Storage of vehicles or rental of towing equipment; 3. Towing by other than a licensed service station or

garage; 4. Towing or service on stolen, unlicensed, illegally

parked or impounded vehicles; 5. The cost of any liquids, parts, materials or services

received at a garage or service facility; and 6. Service on personal use, non-collectible automobiles,

mobile homes, taxicabs, tractors, trucks, boats, camping, travel or other trailers, motorcycles, motor scooters, public conveyance vehicles on display for sale or any other purpose vehicles used in competition or for commercial purposes.

GOLD PLAN

The following coverages apply to this plan and are subject to the exclusions shown in Section X.


II. $100 Roadside Assistance: You will be reimbursed up to a maximum of $100 per disablement if your vehicle is disabled and unable to be driven under its own power as defined below. You will need to contact the facility of your choice and submit a claim to us for reimbursement. Emergency Roadside Assistance covers a maximum of 3 breakdowns per term. No further reimbursement will be provided for the remainder of the term if you exceed this limit.



Stuck: Service to extricate your vehicle from a ditch, snow, mud, or sand. (Cannot be used for everyday snow removal.)




III. $50 Emergency Lockout: You will be reimbursed up to $50 for locksmith assistance if you are locked out of your insured vehicle, providing the following conditions apply:


2. You must be with your vehicle at time of lockout. 3. Private citizen’s assistance is not reimbursable.

IV. Lost Key: When you purchase this coverage you will be provided with a registered numbered key ring card. If your key is lost, return postage is guaranteed and paid by us when placed in the U.S. mail. Upon receipt of the lost key, we will contact you and return your key.

V. $250 Emergency Travel Expense: If the insured vehicle is disabled as a result of an accident or mechanical failure which occurs 50 miles or more from your home, you will be reimbursed up to $50 per day for five days (120 hours) from the time of disablement while your vehicle is being repaired, for a maximum of $250 for any combination of expenses for meals, lodging, car rental or carrier transportation. If the disablement is due to an accident, the accident must be reported to state or local police, and a copy of the report must be submitted with your request for reimbursement. Emergency Travel Expense covers a maximum of 2 breakdowns per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

Car Rental: refers to automobiles obtained from a bona fide car rental agency for use while your vehicle is being repaired.

Local Meals and Lodging: must be purchased in the vicinity of station, garage or body shop where your vehicle is being repaired.

Carrier Transportation: refers to a common carrier licensed to carry passengers for hire, used for transportation to your destination or home.

Accident: refers to the actual colliding of an automobile driven by you with another vehicle or object.

VI. $2,500 Theft Reward: Place your important Theft Reward Decal on the left back window near your front door as a warning to any would-be thief and alert passersby. If your car is stolen, we will assist in its recovery by paying a $2,500 reward for information leading to the arrest and conviction of the person who stole your car. (This reward is not payable to you or your immediate family or law officers.)

VII. $250 Personal Effects: If your car is stolen or vandalized, we will reimburse you up to $250 for any personal effects (does not include automobile parts) stolen or damaged. There must be an incident report made to the state or local police.

VIII. $100 Ambulance Assistance: Should you require the need of an ambulance as a result of a vehicle accident, you will be reimbursed up to $100 to offset the cost. This coverage is not restricted to your own car. You will be reimbursed for ambulance assistance if the accident occurs while:

1. You are in your own car; 2. You are riding in a common carrier such as a bus, train

or taxi; or 3. You are hit by another vehicle.

IX. $100 Car Show Expenses: If your vehicle is disabled due to an accident or mechanical breakdown and as a result you are unable to attend a Car Show, we will reimburse you up to a maximum of $100 for each occurrence for non-refundable:

1. Car show registration fee; and 2. Hotel expenses.

In order to be reimbursed, you must submit receipts containing the name address and telephone number of the company charging the expenses. Car Show Expense covers a maximum of 2 events per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

X. Exclusions:







PLATINUM PLAN

The following coverages apply to this plan and are subject to the exclusions shown in Section XIV.


II. $150 Roadside Assistance: You will be reimbursed up to a maximum of $150 per disablement if your vehicle is disabled and unable to be driven under its own power as defined below. You will need to contact the facility of your choice and submit a claim to us for reimbursement. Emergency Roadside Assistance covers a maximum of 3 breakdowns per term. No further reimbursement will be provided for



the remainder of the annual policy term if you exceed this limit.



Stuck: Service to extricate your vehicle from a ditch, snow, mud or sand. (Cannot be used for everyday snow removal.)


III. $50 Emergency Lockout: You will be reimbursed up to $50 for locksmith assistance if you are locked out of your insured vehicle, providing the following conditions apply:


2. You must be with your vehicle at time of lockout. 3. Private citizen’s assistance is not reimbursable.

IV. Lost Key: When you purchase this coverage you will be provided with a registered numbered key ring card. If your key is lost, return postage is guaranteed and paid by us when placed in the U.S. mail. Upon receipt of the lost key, we will contact you and return your key.

V. $500 Emergency Travel Expense: If the insured vehicle is disabled as a result of an accident or mechanical failure which occurs 50 miles or more from your home, you will be reimbursed up to $100 per day for five days (120 hours) from the time of disablement while your vehicle is being repaired, for a maximum of $500 for any combination of expenses for meals, lodging, car rental or carrier transportation. If the disablement is due to an accident, the accident must be reported to state or local police, and a copy of the report must be submitted with your request for reimbursement. Emergency Travel Expense covers a maximum of 2 breakdowns per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

Car Rental: refers to automobiles obtained from a bona fide car rental agency for use while your vehicle is being repaired.

Local Meals and Lodging: must be purchased in the vicinity of station, garage, or body shop where your vehicle is being repaired.

Carrier Transportation: refers to a common carrier licensed to carry passengers for hire, used for transportation to your destination or home.

Accident: refers to the actual colliding of an automobile driven by you with another vehicle or object.

VI. $5,000 Theft Reward: Place your important Theft Reward Decal on the left back window near your front door as a warning to any would-be thief and alert passersby. If your

car is stolen, we will assist in its recovery by paying a $5,000 reward for information leading to the arrest and conviction of the person who stole your car. (This reward is not payable to you or your immediate family or law officers.)

VII. $500 Personal Effects: If your car is stolen or vandalized, we will reimburse you up to $500 for any personal effects (does not include automobile parts) stolen or damaged. There must be an incident report made to the state or local police.

VIII. $250 Ambulance Assistance: Should you require the need of an ambulance as a result of a vehicle accident, you will be reimbursed up to $250 to offset the cost. This coverage is not restricted to your own car. You will be reimbursed for ambulance assistance if the accident occurs while:

1. You are in your own car; 2. You are riding in a common carrier such as a bus, train

or taxi; or 3. You are hit by another vehicle.

IX. $150 Car Show Expenses: If your vehicle is disabled due to an accident or mechanical breakdown and you are unable to attend a Car Show, we will reimburse you up to a maximum of $150 for non-refundable:

1. Car show registration fee; and 2. Hotel expenses.

In order to be reimbursed, you must submit receipts containing the name address and telephone number of the company charging the expenses. Car Show Expense covers a maximum of 2 events per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

X. $5,000 Bail Bond: If you are arrested for a traffic violation and must post bail to stay out of jail or ensure your appearance in court, you will be reimbursed for the bail bond premium for a required bond up to $5,000.00. Commission of a felony, driving without a valid operator’s permit or under the influence of alcohol, drugs or narcotics are excluded.

XI. $1,000 Legal Defense Benefit: If you must appear in court as a result of a traffic violation, you will be reimbursed up to a maximum of $1,000 per occurrence for the fee charged by an attorney of your choice to defend you according to the following schedule:

Reckless Driving: Trial - $100, Appeal - $100 Manslaughter: Trial - $400, Appeal - $200 Other Traffic Violations: Trial - $50, Appeal - $50

Exclusions: 1. Fines and forfeitures; 2. Commission of a felony; 3. Driving without a valid operator’s permit; or 4. Driving under the influence of alcohol, drugs or

narcotics.

XII. $1,000 Hit and Run Reward: We will pay for information leading to the arrest and conviction of a hit-and-run driver who damages your covered auto or injures you while in your covered auto - up to $1,000. (This reward is not payable to you or your immediate family or law officers.)



XIII. TrailerGuard: If the covered auto is being moved by a trailer or the trailer is being hauled by the covered auto and the trailer is disabled you are entitled to a maximum benefit of $150 per disablement as defined below. You will need to contact the facility of your choice and submit a claim to us for reimbursement. TrailerGuard coverage covers a maximum of 2 disablements per policy term. No further reimbursement will be provided for the remainder of the annual policy term if you exceed this limit.

Towing: If the trailer cannot be used without causing damage, including disablement as a result of an accident.

Flat Tire: Service call to install your inflated spare.

Stuck: Service to extricate the trailer from a ditch, snow, mud or sand. (Cannot be used for everyday snow removal.)

In need of liquids or parts: Service to deliver an emergency supply of gas, oil or water, or other materials or parts needed to get the trailer back on the road.

Lockout Service: If your keys are lost or you are locked out of the trailer, we will reimburse you for locksmith assistance.

XIV. Exclusions









AMENDMENT OF POLICY PROVISIONS MASSACHUSETTS

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

I. DEFINITIONS

The following is added to the Definitions section:

Throughout the policy, "minimum limits" refers to the following limits of liability as required by Massachusetts law, to be provided under a policy of automobile liability insurance:

1. $20,000 for each person, subject to $40,000 for each accident, with respect to "bodily injury"; and

2. $5,000 for each accident with respect to "property damage".

II. PART A - LIABILITY COVERAGE

A. Paragraph A. of the Insuring Agreement is replaced by the following:

A. We will pay damages for "bodily injury" or "property damage" for which any "insured" becomes legally responsible because of an auto accident. Damages include prejudgment interest awarded against the "insured". We will settle or defend, as we consider appropriate, any claim or suit asking for these damages. This applies even if any of the allegations of the suit are groundless, false or fraudulent. In addition to our limit of liability, we will pay all defense costs we incur. Our duty to settle or defend ends when our limit of liability for this coverage has been exhausted by payment of judgments or settlements. We have no duty to defend any suit or settle any claim for "bodily injury" or "property damage" not covered under this policy.

B. The following is added:

Throughout Part A of this policy, with respect to "property damage", ownership, maintenance or use of a vehicle includes its loading and unloading.

C. Paragraph B. of the Limit of Liability provision is replaced by the following:

B. No one will be entitled to receive duplicate payments for the same elements of loss under this coverage and:

1. Part B or Part C of this policy; or

2. Any Underinsured Motorists Coverage or Personal Injury Protection Coverage provided by this policy.

III. PART B - MEDICAL PAYMENTS COVERAGE

Paragraph B. of the Limit of Liability provision is replaced by the following:


1. Part A or Part C of this policy; or 2. Any Underinsured Motorists Coverage or Personal

Injury Protection Coverage provided by this policy.

IV. PART D - COVERAGE FOR DAMAGE TO YOUR AUTO

A. The following is added to Paragraph B. of the Limit of Liability provision:

Whenever the appraised cost of repair plus the probable salvage value may be reasonably expected to exceed the actual cash value of "your covered auto" or any "trailer", we shall determine the actual cash value of the "your covered auto" or "trailer". This determination shall be based on consideration of all of the following factors:

1. The retail book value for a motor vehicle of like kind and quality, but for the damage incurred;

2. The price paid for the "your covered auto" or "trailer", plus the value of prior improvements to the "your covered auto" or "trailer" at the time of the accident, less appropriate depreciation;

3. The decrease in value of the "your covered auto" or "trailer", resulting from prior unrelated damage which is detected by the appraiser; and

4. The actual cost of purchase of an available motor vehicle of like kind and quality but for the damage sustained.

B. The following is added to the Payment of Loss provision:

1. If we have a plan approved by the Commissioner of Insurance providing for direct payment for loss to the vehicle(s) insured under Part D prior to our receipt of a claim form stating that the repair work described in an appraisal made pursuant to regulations promulgated by the auto damage appraisers licensing board has been completed, then the following applies:

a. If you elect not to repair the vehicle for which a claim payment has been made; or

b. If you have not provided us with the claim form described above;



we will decrease the actual cash value of the vehicle by the amount of damage sustained plus any applicable deductible until we receive a claim form described above.

2. If you choose not to accept payment under our plan described in Paragraph B.1. above, or if we do not have a plan approved by the Commissioner of Insurance that provides for direct payment for loss to the vehicle(s) insured under Part D, then the following applies:

a. If you instruct us in writing, we will pay the repair shop directly within seven days of receipt of the claim form that states that the repair work described in an appraisal made pursuant to the regulations promulgated by the auto damage appraisers licensing board has been completed.

Receipt of the claim form described above by registered mail shall be sufficient proof of receipt.

b. If you elect not to repair the vehicle, or do not provide us with a claim form described above, we will decrease the actual cash value of the vehicle by the amount of damage sustained.

c. If you do not provide us with a claim form described above, we will pay only the decrease in actual cash value of the vehicle, less any deductible.

C. The Appraisal provision is replaced by the following:

APPRAISAL

A. If you and we fail to agree as to the amount of loss, each will, on the written demand of either, within 60 days after we receive the proof of loss, select a competent and disinterested appraiser. The appraisal will be made at a reasonable time and place. The appraisers will first select a competent and disinterested umpire, and failing for 15 days to agree upon the umpire, at our request or your request, the umpire will be selected by a judge of a court of record in the county and state in which the appraisal is pending. The appraisers will then appraise the loss, stating separately the actual cash value and the amount of loss. If they fail to agree, they will submit their differences to the umpire. An award in writing by any two will determine the amount of loss. Each party will:

1. Pay its chosen appraiser; and 2. Bear the expenses of the appraisal and umpire

equally.

B. We do not waive any of our rights under this policy by agreeing to an appraisal.

D. The following provision is added and applies in place of any conflicting policy provision:

MANDATORY INSPECTION

1. We have the right as authorized by Massachusetts regulation to inspect any:

a. Private passenger auto; or b. Pickup or van;

which you insure or intend to insure for Coverage For Damage To Your Auto under this policy.

2. When we require an inspection you must: a. Cooperate; and b. Make the vehicle available for the inspection.

V. PART E - DUTIES AFTER AN ACCIDENT OR LOSS

Paragraphs A. and D. are replaced by the following:

A. We must be notified promptly of how, when and where the accident or loss happened. Notice should also include the names and addresses of any injured persons and of any witnesses. Notice to our authorized representative is considered notice to us.

D. A person seeking Coverage For Damage To Your Auto must also:

1. Take reasonable steps after a loss to protect "your covered auto" or any "trailer" and its equipment from further loss. We will pay reasonable expenses incurred to do this.

2. Promptly notify the police in the event of larceny, robbery or pilferage.

3. Permit us to inspect and appraise the damaged property before its repair or disposal.

4. In the event of loss due to fire, submit a signed statement to the fire department that contains information concerning the fire loss as required by the state fire marshal.

VI. PART F - GENERAL PROVISIONS

The Termination provision of Part F is replaced by the following:

TERMINATION

A. Cancellation

This policy may be cancelled during the policy period as follows:

1. The named insured shown in the Declarations may cancel by:

a. Returning this policy to us; or b. Giving us advance written notice of the date

cancellation is to take effect. 2. We may cancel by mailing notice at least 20 days

prior to the effective date to the named insured shown in the Declarations at the address shown in this policy and obtaining a certificate of mailing receipt issued by the United States Post Office.

3. We will cancel only: a. For nonpayment of premium; or b. If your driver's license or that of:

(1) Any driver who lives with you; or (2) Any driver who customarily uses "your

covered auto" has been suspended or revoked. This must have

occurred: (1) During the policy period; or (2) Since the last anniversary of the original

effective date if the policy period is other than one year; or

c. If the policy was obtained through material misrepresentation.



B. Nonrenewal

If we decide not to renew or continue this policy, we will mail notice by obtaining a certificate of mailing receipt issued by the United States Post Office to the named insured shown in the Declarations at the address shown in this policy. Notice will be mailed at least 45 days before the end of the policy period. Subject to this notice requirement, if the policy period is one year or longer, we will have the right not to renew or continue this policy at each anniversary of its original effective date.

C. Automatic Termination

If we offer to renew or continue and you or your representative does not accept, this policy will automatically terminate at the end of the current policy period. Failure to pay the required renewal or continuation premium when due shall mean that you have not accepted our offer.

If you obtain other insurance on "your covered auto", any similar insurance provided by this policy will terminate as to that auto on the effective date of the other insurance.

D. Termination By Operation Of Law

This policy will terminate with respect to "your covered auto" by operation of law in any of the following circumstances:

1. Another insurer files with the Registrar of Motor Vehicles a certificate of insurance covering the same "your covered auto" insured under the terminating policy. In this case, the policy will terminate on the date on which a new certificate of insurance filed with the Registrar of Motor Vehicles becomes effective.

2. You sell or transfer title to such "your covered auto". In this case, the coverage under this policy will terminate 30 days from the date of the sale or transfer, unless within the 30-day period you transfer the registration of "your covered auto" to a "newly acquired auto" that is a replacement vehicle.

3. You surrender the registration plates for such "your covered auto" to the Registrar of Motor Vehicles.

E. Other Termination Provisions

1. We may deliver any notice instead of mailing it. Proof of mailing of any notice shall be sufficient proof of notice.

2. If this policy is cancelled, you may be entitled to a premium refund. If so, we will send you the refund. The premium refund, if any, will be computed according to our manuals. However, making or offering to make the refund is not a condition of cancellation.

3. The effective date of cancellation stated in the notice shall become the end of the policy period.




UNINSURED MOTORISTS COVERAGE MASSACHUSETTS


PART C – UNINSURED MOTORISTS COVERAGE is replaced in its entirety by the following:

INSURING AGREEMENT

A. We will pay compensatory damages which an "insured" is legally entitled to recover from the owner or operator of an "uninsured motor vehicle" because of "bodily injury":

1. Sustained by an "insured"; and

2. Caused by an accident.

The owner's or operator's liability for these damages must arise out of the ownership, maintenance or use of the "uninsured motor vehicle".

Any judgment for damages arising out of a suit brought without our written consent is not binding on us.

B. "Insured" as used in this Part means:

1. You or any "family member" “occupying” “your covered auto”.

2. Any other person "occupying" "your covered auto".

3. Any person for damages that person is entitled to recover because of "bodily injury" to which this coverage applies sustained by a person described in 1. or 2. above.

C. "Uninsured motor vehicle" means a land motor vehicle or trailer of any type:

1. To which no bodily injury liability bond or policy applies at the time of the accident.

2. To which a bodily injury liability bond or policy applies at the time of the accident. In this case its limit for bodily injury liability must be less than the applicable minimum limits for bodily injury liability required by the compulsory automobile insurance law of Massachusetts.

3. Which is a hit-and-run vehicle whose operator or owner cannot be identified and which hits:

a. You or any "family member";

b. A vehicle which you or any "family member" are "occupying"; or

c. "Your covered auto".

4. To which a bodily injury liability bond or policy applies at the time of the accident but the bonding or insuring company:

a. Denies coverage; or b. Has been declared to be insolvent by a court of

competent jurisdiction: (1) As of the date of the accident; or

(2) Within one year after the date of the accident.

However, "uninsured motor vehicle" does not include any vehicle or equipment:

1. Owned by or furnished or available for the regular use of you or any "family member".

2. Owned or operated by a self-insurer under any applicable motor vehicle law, except a self-insurer which is or becomes insolvent.

3. Owned by any governmental unit or agency unless the insurer of the vehicle or equipment owned by the governmental unit or agency is or becomes insolvent.

4. Operated on rails or crawler treads.

5. Designed mainly for use off public roads while not on public roads.

6. While located for use as a residence or premises.

EXCLUSIONS

A. We do not provide Uninsured Motorists Coverage for "bodily injury" sustained:

1. By you while "occupying", or when struck by, any motor vehicle owned by you for which the minimum limits of liability as required by Massachusetts law to be provided under a motor vehicle liability policy are not in effect.

2. By any "family member" while "occupying", or when struck by, any motor vehicle owned by that "family member" for which the minimum limits of liability as required by Massachusetts law to be provided under a motor vehicle liability policy are not in effect.

B. We do not provide Uninsured Motorists Coverage for "bodily injury" sustained by:

1. Any "insured" if that "insured" or the legal representative settles the "bodily injury" claim and such settlement prejudices our right to recover payment.

2. You while "occupying" "your covered auto" when it is being used as a public or livery conveyance and which is not insured for this coverage under this policy. This Exclusion (B.2.) does not apply to a share-the-expense car pool.

3. Any "insured" while "occupying" "your covered auto" without your express or implied consent but only to the extent that the limits of liability for this coverage exceed the lesser of:

a. The limit of liability for this coverage; or

b. $35,000 for each person, subject to $80,000 for each accident.



C. This coverage shall not apply directly or indirectly to benefit any insurer or self-insurer under any of the following or similar law:

1. Workers' compensation law; or 2. Disability benefits law.

D. We do not provide Uninsured Motorists Coverage for punitive or exemplary damages.

LIMIT OF LIABILITY

A. The limit of liability shown in the Declarations for each person for Uninsured Motorists Coverage is our maximum limit of liability for all damages, including damages for care, loss of services or death, arising out of "bodily injury" sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Declarations for each accident for Uninsured Motorists Coverage is our maximum limit of liability for all damages for "bodily injury" resulting from any one accident.

This is the most we will pay regardless of the number of:

1. "Insureds"; 2. Claims made; 3. Vehicles or premiums shown in the Declarations; or 4. Vehicles involved in the accident.


1. Part A or Part B of this policy; or 2. Any Underinsured Motorists Coverage or Personal

Injury Protection Coverage provided by this policy.

C. We will not make a duplicate payment under this coverage for any element of loss for which payment has been made by or on behalf of persons or organizations who may be legally responsible.

D. We will not pay for any element of loss if a person is entitled to receive payment for the same element of loss under any of the following or similar law:

1. Workers' compensation law; or 2. Disability benefits law.

OTHER INSURANCE

If there is other applicable insurance available under more than one policy or provision of coverage that is similar to the insurance provided under this endorsement:

A. Any recovery for damages under all such policies or provisions of coverage may equal but not exceed the highest applicable limit for any one vehicle under any insurance providing coverage on the same level of priority.

B. The following priorities of recovery apply:

First Any policy affording Uninsured Motorists Coverage to the "insured" as a named insured

Second Any policy affording Uninsured Motorists Coverage to the "insured" as a family member

Third The Uninsured Motorists Coverage applicable to the vehicle the "insured" was "occupying" at the time of the accident

However, with respect to you while "occupying" a vehicle owned by you, only the Uninsured Motorists Coverage applicable to that vehicle will apply.

C. We will pay only our share of the loss. Our share is the proportion that our limit of liability bears to the total of all limits applicable on the same level of priority.

ARBITRATION

A. If we and an "insured" do not agree:

1. Whether that "insured" is legally entitled to recover damages; or

2. As to the amount of damages which are recoverable by that "insured";

from the owner or operator of an "uninsured motor vehicle", then the matter may be arbitrated. However, disputes concerning coverage under this Part may not be arbitrated.

Both parties must agree to arbitration. If so agreed, each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having juris-diction.

B. Each party will:

1. Pay the expenses it incurs; and 2. Bear the expenses of the third arbitrator equally.

C. Unless both parties agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law as to procedure and evidence will apply. A decision agreed to by at least two of the arbitrators will be binding as to:

1. Whether the "insured" is legally entitled to recover damages; and

2. The amount of damages. This applies only if the amount does not exceed the minimum limit for bodily injury liability specified by the compulsory automobile insurance law of Massachusetts. If the amount exceeds that limit, either party may demand the right to a trial. This demand must be made within 60 days of the arbitrators' decision. If this demand is not made, the amount of damages agreed to by the arbitrators will be binding.

PART F – GENERAL PROVISIONS

The following is added to the Our Right To Recover Payment provision of Part F:

OUR RIGHT TO RECOVER PAYMENT

We shall be entitled to a recovery under Paragraph A. or B. only after the person has been fully compensated for damages.




UNDERINSURED MOTORISTS COVERAGE MASSACHUSETTS


With respect to the coverage provided by this endorsement, the provisions of the policy apply unless modified by the endorsement.

INSURING AGREEMENT

A. We will pay compensatory damages which an "insured" is legally entitled to recover from the owner or operator of an "underinsured motor vehicle" because of "bodily injury":

1. Sustained by an "insured"; and

2. Caused by an accident.

The owner's or operator's liability for these damages must arise out of the ownership, maintenance or use of the "underinsured motor vehicle".

We will pay under this coverage only if 1. or 2. below applies:

1. The limits of liability under any bodily injury liability bonds or policies applicable to the "underinsured motor vehicle" have been exhausted by payment of judgments or settlements; or

2. A tentative settlement has been made between an "insured" and the insurer of the "underinsured motor vehicle" and we:

a. Have been given prompt written notice of such tentative settlement; and

b. Advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification.

B. "Insured" as used in this endorsement means:

1. You or any "family member" “occupying” “your covered auto”.

2. Any other person "occupying" "your covered auto".

3. Any person for damages that person is entitled to recover because of "bodily injury" to which this coverage applies sustained by a person described in 1. or 2. above.

C. "Underinsured motor vehicle" means a land motor vehicle or trailer of any type to which a bodily injury liability bond or policy applies at the time of the accident but its limit for bodily injury liability is less than the limit of liability for this coverage.

However, "underinsured motor vehicle" does not include any vehicle or equipment:

1. Owned by or furnished or available for the regular use of you or any "family member".

2. Owned by any governmental unit or agency unless the insurer of the vehicle or equipment owned by the governmental unit or agency is or becomes insolvent.

3. Operated on rails or crawler treads.

4. Designed mainly for use off public roads while not upon public roads.

5. While located for use as a residence or premises.

6. Owned or operated by a person qualifying as a self-insurer under any applicable motor vehicle law.

7. To which a bodily injury liability bond or policy applies at the time of the accident but the bonding or insuring company:

a. Denies coverage; or b. Is or becomes insolvent.

EXCLUSIONS

A. We do not provide Underinsured Motorists Coverage for "bodily injury" sustained:

1. By you while "occupying", or when struck by, any motor vehicle owned by you for which the minimum limits of liability as required by Massachusetts law to be provided under a motor vehicle liability policy are not in effect.

2. By any "family member" while "occupying", or when struck by, any motor vehicle owned by that "family member" for which the minimum limits of liability as required by Massachusetts law to be provided under a motor vehicle liability policy are not in effect.

B. We do not provide Underinsured Motorists Coverage for "bodily injury" sustained by:

1. You while "occupying" "your covered auto" when it is being used as a public or livery conveyance and which is not insured for this coverage under this policy. This Exclusion (B.1.) does not apply to a share-the-expense car pool.

2. Any "insured" using a vehicle without a reasonable belief that that "insured" is entitled to do so. This Exclusion (B.2.) does not apply to a "family member" using "your covered auto" which is owned by you.

C. This coverage shall not apply directly or indirectly to benefit any insurer or self-insurer under any of the following or similar law:

1. Workers' compensation law; or

2. Disability benefits law.

D. We do not provide Underinsured Motorists Coverage for punitive or exemplary damages.

LIMIT OF LIABILITY

A. The limit of liability shown in the Declarations for each person for Underinsured Motorists Coverage is our maximum limit of liability for all damages, including damages for care, loss of services or death, arising out of "bodily injury" sustained by any one person in any one accident. Subject to this limit for each person, the limit of liability shown in the Declarations for each accident for Underinsured Motorists Coverage is our maximum limit of liability for all damages for "bodily injury" resulting from any one accident.



This is the most we will pay regardless of the number of:

1. "Insureds";

2. Claims made;

3. Vehicles or premiums shown in the Declarations; or

4. Vehicles involved in the accident.

B. The limit of liability shall be reduced by all sums paid because of the "bodily injury" by or on behalf of persons or organizations who may be legally responsible. This includes all sums paid under Part A of this policy.

C. No one will be entitled to receive duplicate payments for the same elements of loss under this coverage and:

1. Part A, Part B or Part C of this policy; or

2. Personal Injury Protection Coverage.

D. We will not make a duplicate payment under this coverage for any element of loss for which payment has been made by or on behalf of persons or organizations who may be legally responsible.

E. We will not pay for any element of loss if a person is entitled to receive payment for the same element of loss under any of the following or similar law:

1. Workers' compensation law; or

2. Disability benefits law.

OTHER INSURANCE

If there is other applicable insurance available under more than one policy or provision of coverage that is similar to the insurance provided under this endorsement:

A. Any recovery for damages under all such policies or provisions of coverage may equal but not exceed the highest applicable limit for any one vehicle under any insurance providing coverage on the same level of priority.

B. The following priorities of recovery apply:

First Any policy affording Underinsured Motorists Coverage to the "insured" as a named insured

Second Any policy affording Underinsured Motorists Coverage to the "insured" as a family member

Third The Underinsured Motorists Coverage applicable to the vehicle the "insured" was "occupying" at the time of the accident

However, with respect to you while "occupying" a vehicle owned by you, only the Underinsured Motorists Coverage applicable to that vehicle will apply.

C. We will pay only our share of the loss. Our share is the proportion that our limit of liability bears to the total of all limits applicable on the same level of priority.

ARBITRATION

A. If we and an "insured" do not agree:

1. Whether that "insured" is legally entitled to recover damages; or

2. As to the amount of damages which are recoverable by that "insured";

from the owner or operator of an "underinsured motor vehicle", then the matter may be arbitrated. However, disputes concerning coverage under this endorsement may not be arbitrated.

Both parties must agree to arbitration. If so agreed, each party will select an arbitrator. The two arbitrators will select a third. If they cannot agree within 30 days, either may request that selection be made by a judge of a court having jurisdiction.

B. Each party will:

1. Pay the expenses it incurs; and

2. Bear the expenses of the third arbitrator equally.

C. Unless both parties agree otherwise, arbitration will take place in the county in which the "insured" lives. Local rules of law as to procedure and evidence will apply. A decision agreed to by at least two of the arbitrators will be binding as to:

1. Whether the "insured" is legally entitled to recover damages; and

2. The amount of damages. This applies only if the amount does not exceed the minimum limit for bodily injury liability specified by the compulsory automobile insurance law of Massachusetts. If the amount exceeds that limit, either party may demand the right to a trial. This demand must be made within 60 days of the arbitrators' decision. If this demand is not made, the amount of damages agreed to by the arbitrators will be binding.

ADDITIONAL DUTIES

A person seeking coverage under this endorsement must also promptly:

1. Send us copies of the legal papers if a suit is brought; and

2. Notify us in writing of a tentative settlement between the "insured" and the insurer of the "underinsured motor vehicle" and allow us 30 days to advance payment to that "insured" in an amount equal to the tentative settlement to preserve our rights against the insurer, owner or operator of such "underinsured motor vehicle".

GENERAL PROVISIONS

The following is added to the Our Right To Recover Payment provision in Part F:

OUR RIGHT TO RECOVER PAYMENT

We shall be entitled to a recovery under Paragraph A. or B. only after the person has been fully compensated for damages.

Our rights do not apply under Paragraph A. with respect to Underinsured Motorists Coverage if we:

1. Have been given prompt written notice of a tentative settlement between an "insured" and the insurer of an "underinsured motor vehicle"; and



2. Fail to advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification.

If we advance payment to the "insured" in an amount equal to the tentative settlement within 30 days after receipt of notification:

1. That payment will be separate from any amount the "insured" is entitled to recover under the provisions of Underinsured Motorists Coverage; and

2. We also have a right to recover the advanced payment.




NAMED DRIVER EXCLUSION ENDORSEMENT MASSACHUSETTS


It is agreed that no coverage is afforded under the policy for the person(s) excluded below or on the policy Declarations. We will not be held liable for any accident, damages, losses, or claims arising out of the operation or use of any vehicle whether or not that operation or use was with the express or implied permission of an “insured” under the policy. This coverage exclusion applies to the following:

• Medical Payments,

• Agreed Value Other than Collision; or

• Agreed Value Other than Collision and Collision.

In consideration of the premium for which the policy is written, it is agreed that the coverage provided by this policy to the person(s)

described in the Schedule below shall be excluded; except that liability coverage shall be no greater than the minimum financial

responsibility limits applicable at the time of loss and the interest of any loss payee applicable at the time of loss.

WARNING - Owners of the vehicle and others legally responsible for the acts of the named excluded person remain fully personally responsible. Name of Excluded Person(s):

The undersigned acknowledge and understand that the Named Driver Exclusion Endorsement shall remain in effect for the term of the policy and for each renewal, reinstatement, substitute, modified replacement or amended policy, unless discontinued by us. Signature of Named Insured: ___________________________________ Date Signed___________________ Signature of Excluded Person: __________________________________Date Signed___________________




ANTIQUE AUTO COVERAGE ENDORSEMENT

MASSACHUSETTS Please read this endorsement carefully, it amends the policy as follows: I. DEFINITIONS Item A. is deleted and replaced with the following: A. Throughout this policy, “you” and “your” refer to: 1. The “named insured” shown in the

Declarations; and 2. The spouse if a resident of the same household. Item C. is amended to delete “pickup or van”. Items I. and J. are deleted and replaced by the following: I. “Trailer” means a vehicle designed to: 1. Carry “your covered auto”; and 2. Be pulled by a: a. Private passenger type auto; b. Pick-up; or c. Sedan delivery or panel truck.

J. “Your covered auto” means: 1. Any “Collector vehicle” shown in the

Declarations. 2. Any newly acquired “Collector vehicle” of

which you acquire ownership during the policy period, provided that you ask us to insure it within thirty (30) days after you become the owner. If the vehicle replaces one shown in the Declarations, you have to ask us to insure it within thirty (30) days only if you wish Coverage for Damage to Your Auto to apply to the replacement vehicle. If you ask us to insure a newly acquired “Collector vehicle” after the thirty (30) days has elapsed, any coverage we provide for a newly acquired “Collector vehicle” will begin at the time we receive your request for coverage.

3. Any “trailer” you own shown in the Declarations, provided it is primarily used to transport “your covered auto” to: exhibitions; club activities; parades; or other functions of public interest.

Item K. is deleted in its entirety. The following definitions are added: L. “Antique vehicle” means a vehicle which is: 1. At least twenty five years old; 2. Used primarily for: exhibitions; club activities;

parades or other functions of public interest; occasional pleasure drives;

3. Not used primarily for transportation of persons or goods; and

4. Driven no more than the mileage tier indicated in the Declarations during an annual policy term.

M. “Classic vehicle” means a motor vehicle that is:

1. Newer than twenty five years old where the vehicle:

a. Is considered to be appreciating in value, and is either:

i. of unique or rare design; or ii. of limited production. 2. Used for: exhibitions; club activities; parades; or

other functions of public interest; occasional pleasure drives;

3. Not used for general transportation; and 4. Driven no more than the mileage tier indicated

in the Declarations during an annual policy term.

N. “Modified vehicle” means a motor vehicle that is:

1. Modified from its original specifications; 2. Used for: exhibitions; club activities; parades; or




Replica or kit cars are considered “Modified vehicles”.

O. “Collector vehicle” means a motor vehicle that is: 1. Any “Antique vehicle”; 2. Any “Classic vehicle”; or 3. Any “Modified vehicle”.

II. PART A. LIABILITY COVERAGE INSURING AGREEMENT, item B.1 is replaced with

the following: 1. “You” or any “family member” for the

ownership, maintenance or use of “your covered auto”.

EXCLUSIONS, item A.7 is deleted and replaced with the

following: 7. Maintaining or using any vehicle while that

“insured” is employed or otherwise engaged in any “business” (other than farming or ranching) not described in Exclusion (A.6).



This Exclusion (A.7) does not apply to the maintenance or use of a:

a. Your “covered auto”; or b. “Trailer” used with “your covered auto”.

EXCLUSIONS, item B.1 is deleted and replaced with the

following: B. We do not provide Liability Coverage for the ownership,

maintenance or use of: 1. Any vehicle which: a. Is designed mainly for use off public

roads; or b. To any golf cart. This exclusion (B.1) does not apply: a. While such vehicle is being used by an

“insured” in a medical emergency; or b. To any “trailer” or collector farm tractor. III. PART D - COVERAGE FOR DAMAGE TO YOUR

AUTO INSURING AGREEMENT, item A. is deleted and

replaced with the following:

A. We will pay for sudden, direct and accidental loss to "your covered auto" or any "trailer”, including their equipment, minus any applicable deductible shown in the Declarations. If loss to more than one "your covered auto" or "trailer" results from the same "collision", only the highest applicable deductible will apply. We will pay for loss to "your covered auto" caused by:

1. Other than “collision” only if the Declarations indicate that Other than Collision coverage is provided for that auto.

2. “Collision” only if the Declarations indicate that Collision coverage is provided for that auto.

INSURING AGREEMENT, item B. is deleted and

replaced with the following: B. "Collision" means the upset of "your covered auto"

or their impact with another vehicle or object. Loss caused by the following is considered other than

"collision": 1. Missiles or falling objects; 2. Fire; 3. Theft or larceny; 4. Explosion or earthquake; 5. Windstorm; 6. Hail, water or flood; 7. Malicious mischief or vandalism; 8. Riot or civil commotion; 9. Contact with bird or animal; or 10. Breakage of glass.

If breakage of glass is caused by a "Collision", you

may elect to have it considered a loss caused by "Collision".

INSURING AGREEMENT, item C is deleted in its entirety.

TRANSPORTATION EXPENSES is deleted in its

entirety. The following coverage is added: SPARE PARTS COVERAGE

Spare parts are additional parts that you own for “your covered auto”. We will pay up to $500 for direct and accidental loss to spare parts and accessories to “your covered auto”. However, we will pay for loss covered by collision or other than collision coverages only if the Declarations indicate that such coverage is afforded.

We do not cover:

1. Parts and accessories held for sale by you; or 2. The property of others in your care, custody

and control.

EXCLUSIONS, items 1, 2, 4, 6, 8, 10 and 12 are deleted

and replaced as follows:

1. Loss to “your covered auto” which occurs while

it is being used as a public conveyance. 2. Loss or damage caused by insects or vermin,

dampness, mold, freezing, temperature extremes; mechanical or electrical breakdown or failure, wear and tear, or road damage to tires.

4. Loss to any electronic equipment and any

accessories except if permanently installed.

6. A total loss to “your covered auto” due to

destruction or confiscation by governmental or civil authorizes. This exclusion does not apply to the interests of Loss Payees in “your covered auto”.

8. Loss or damage intentionally caused or directed

by “you” or any “family member”.

10. Loss to any custom furnishings or equipment in

or upon any collectible vehicle. Custom furnishings or equipment include but are not limited to:

a. Special carpeting or insulation;

b. Furniture or bars; or

c. Height extending roofs.

12. Loss to “your covered auto” located inside a

facility designed for racing, for the purpose of competing in, participating in, practicing or preparing for any racing, speed contest or driver’s education event.



EXCLUSIONS, 11 and 13 are deleted in their entirety. The following EXCLUSIONS are added:

14. Loss to any covered auto being maintained,

used, or held by any person or dealer for consignment or sale.

15. Loss to “your covered auto” as a result of anyone causing you to voluntarily part with it as a result of any trick or scheme; false pretense.

16. Loss or damage caused by rot, rust, corrosion, discoloration, gradual deterioration or fading which is not a result of a covered loss.

17. We will not pay for loss to car covers; items used for car covers, car bras; or tarps.

LIMIT OF LIABILITY The following are added to Sections A. and B.: Agreed Value Coverage In the event of loss to “your covered auto” we will, subject

to the applicable limit of liability shown in the Declarations:

A. Repair or replace the damaged or stolen property with like kind and quality if the amount necessary to repair or replace such property is less than the limit of liability shown in the Declarations; or

B. Pay the agreed value shown on the Declarations page less any deductible applicable, if the amount to repair or replace the property is equal to or greater than the limit of liability or if the vehicle is deemed to be a total loss. The agreed value for each vehicle shown in the Declarations is increased by two percent (2%) after each quarter to a maximum of six percent (6%) after the effective date.

We extend our limit of liability to cover additional or

replacement “Collector vehicle” acquired by you during the policy period but not to exceed:

1. The verifiable value; or 2. The highest agreed value for any single vehicle

currently on the policy; or 3. $100,000; or 4. The purchase price, whichever is less.

Such additional or replacement vehicles must be reported to us within 30 days of purchase for coverage to be extended.

PAYMENT OF LOSS, The last sentence, is deleted and replaced with the following:

If we pay for loss in money, our payment will include the applicable sales tax for the damaged or stolen property subject to the maximum limit of liability shown in the Declarations.

OTHER SOURCES OF RECOVERY is deleted and

replaced with the following: OTHER SOURCES OF RECOVERY If other sources of recovery also cover the loss, we will pay

only our share of the loss. Our share is the proportion that our limit of liability bears to the total of all applicable limits.

The following conditions are added:

VEHICLE TRAILER

Your “trailer" is covered only for physical loss or damage to the “trailer” itself. No liability coverage is provided for your “trailer”. We will cover your "trailer" for up to the amount of insurance, and less any applicable deductible, specified in the Declarations. Coverage is subject to all of the applicable terms and conditions of this policy.

REINSTATEMENT OF LIMIT

A loss to “your covered auto” reduces our liability limit by the amount of the loss under the appropriate coverage. The limit of liability for the individual vehicle will remain reduced until repair or replacement of the vehicle has been completed and proof of repair is provided to us.




OTHER THAN COLLISION COVERAGE GLASS OPTIONS – MASSACHUSETTS


With respect to the coverage provided by this endorsement, the provisions of the policy apply unless modified by this endorsement.

PART D - COVERAGE FOR DAMAGE TO YOUR AUTO

The following is added to Paragraph A. of the Insuring Agreement:

If the Declarations indicates that Other Than Collision Coverage applies, we will pay:

A. The cost of repairing or replacing damaged glass on "your covered auto" or any “trailer” without a deductible, if Full Glass Coverage is indicated as applicable in the Declarations; or

B. The cost of repairing or replacing damaged glass on "your covered auto" or any “trailer”, minus a deductible of $100, if the $100 Glass Deductible is indicated as applicable in the Declarations.



COLLISION COVERAGE WAIVER OF DEDUCTIBLE – MASSACHUSETTS

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. The deductible amount shown on the Declarations Page for Collision coverage does not apply to any auto to which this endorsement applies as shown on the Declarations Page if: 1. That auto was legally parked when struck by another auto owned by an identified person. 2. The auto was struck in the rear by another auto moving in the same direction and owned by an identified person. 3. The operator of the other auto was convicted of any of the following violations: a. Operating under the influence of alcohol, marijuana or a narcotic drug. b. Driving the wrong way on a one-way street. c. Operating at an excessive rate of speed. d. Any similar violations of any similar law of another state in which the accident occurs. However, we will not pay if the operator of “your covered auto” was also convicted of one of the violations. 4. You are entitled to recover in court against an identified person for some reason other than those listed above. (Description of Auto):



AMENDATORY ENDORSEMENT FOR ANTIQUE MOTORCYCLE COVERAGE MASSACHUSETTS

With respect to “motorcycles” and coverages described in the Declarations, the provisions of the Policy apply unless modified by this endorsement. I. DEFINITIONS Item J. is deleted and replaced by the following: J. “Your covered auto” means: 1. Any “motorcycle” as shown in the Declarations. 2. Any newly acquired “motorcycle” of which you

acquire ownership during the policy period, provided that you ask us to insure it within thirty (30) days after you become the owner. If the vehicle replaces one shown in the Declarations, you have to ask us to insure it within thirty (30) days only if you wish Coverage for Damage to Your Auto to apply to the replacement vehicle. If you ask us to insure a newly acquired “motorcycle” after the thirty (30) days has elapsed, any coverage we provide for a newly acquired “motorcycle” will begin at the time we receive your request for coverage.

The following definition is added:

“Motorcycle” means a motorcycle that is: 1. Considered to be appreciating in value, and is

either: a. Of unique or rare design; or b. Of limited production. 2. Used for: exhibitions; club activities; parades;

or other functions of public interest; occasional pleasure drives;



II. PART A - LIABILITY COVERAGE Item B. under INSURING AGREEMENT is deleted

and replaced with the following: B. “Insured” as used in this Part means: 1. You or any “family member” for the

ownership, maintenance, or use of “your covered auto.”

2. Any person using “your covered auto.” 3. For “your covered auto,” any person or

organization but only with respect to legal responsibility for acts or omissions of a person for whom coverage is afforded under this Part.

EXCLUSIONS A, item 10 is added with respect to any vehicle for which the Declarations indicates that the passenger hazard is excluded:

10. We do not provide Liability Coverage for any

“Insured” for “bodily injury” to any person or “insured” while “occupying” the described “motorcycle”.


following: 1. We do not provide Liability Coverage for the

ownership, maintenance, or use of any vehicle which is designed mainly for use off public roads.

This exclusion (B.1.) does not apply while such

vehicle is being used by an “insured” in a medical emergency.


EXCLUSIONS, item 1. is deleted and replaced by the

following: 1. We do not provide Medical Payments Coverage

for any person or “insured” for “bodily injury” sustained while “occupying” “your covered auto” unless it is insured for Medical Payments Coverage under this endorsement.

IV. PART D - COVERAGE FOR DAMAGE TO YOUR

AUTO

Under LIMIT OF LIABILITY Sections A. and B. are deleted and replaced by the following:

Agreed Value Coverage In the event of loss to “your covered auto” we will, subject





B. Pay the agreed value shown on the Declarations page

less any deductible applicable, if the amount to repair or replace the property is equal to or greater than the limit of liability or if the vehicle is deemed to be a total loss. The agreed value for each vehicle shown in the Declarations is increased by two percent (2%) after each quarter to a maximum of six percent (6%) after the effective date.

Upon expiration of the policy period, the limit reverts back to the agreed value shown in the Declarations. This amount is used to process your renewal unless you request a change in the amount of insurance to which we must also agree.

We extend our limit of liability to cover any

additional or replacement “motorcycle” acquired by you during the policy period but not to exceed:

1. The verifiable value; or 2. The highest agreed value for any single

“motorcycle” currently on the policy; or 3. $25,000; or 4. The purchase price, whichever is less. Such additional or replacement vehicles must be

reported to us within 30 days of purchase for coverage to be extended.


AH9675ERR-0316 © American International Group, Inc. All rights reserved. Page 1 of 1


VEHICLE / COVERAGE SCHEDULE

MASSACHUSETTS

NO.

YEAR

TRADE NAME

BODY TYPE

MODEL

IDENTIFICATION NO.

COVERAGE AMOUNT

OTHER THAN COLLISION

COLLISION

PART

COVERAGES - LIMITS

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

M1981MAA-0316 © American International Group, Inc. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc.,


COLLECTOR VEHICLE INSURANCE APPLICATION – MASSACHUSETTS

A. APPLICANT INFORMATION APPLICANT NAME (MR / MRS/ MS) (Enter your name(s) as it appears on your vehicle registration)

MAILING ADDRESS CITY STATE ZIP COUNTY

GARAGING ADDRESS (If different than residence) CITY STATE ZIP COUNTY

DAYTIME PHONE NUMBER EVENING PHONE NUMBER CELL PHONE NUMBER

MARITAL STATUS EMAIL ADDRESS

HOW MANY YEARS HAVE YOU BEEN INVOLVED IN THE COLLECTOR VEHICLE HOBBY? OCCUPATION

PLEASE LIST ANY COLLECTOR VEHICLE CLUBS THAT YOU BELONG TO:

IS THE COLLECTOR VEHICLE CURRENTLY INSURED WITH ANOTHER COMPANY? IF YES, INDICATE COMPANY:

Yes No

B. HOUSEHOLD DRIVERS List all household residents (licensed or not), dependents (including those away at school) and regular operators.

NAME DATE OF

BIRTH

RELATIONSHIP

TO APPLICANT DRIVERS LICENSE NUMBER & STATE

YEARS

LICENSED

OPERATES

COLLECTOR

VEHICLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household

Member 3

Yes No Yes No

Household

Member 4

Yes No Yes No

REGULAR USE VEHICLES

(YEAR / MAKE / MODEL)

IS THIS A

COMPANY

VEHICLE?

Current INSURANCE COMPANY

REGULAR USE VEHICLE COVERAGE LIMITS

LIABILITY (EX. $100/300) UM/UIM (EX. $100/300)

#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD

In the last 3 years, have you or any household driver had any convictions for: moving violations, suspensions, accidents, alcohol/drug related offenses or

careless/reckless driving; or any insurance claims: If so, please describe below.

Applicant Yes No

Household

Member 2 Yes No

Household

Member 3 Yes No

Household

Member 4 Yes No

PRODUCER # ____________________

QUOTE #________________________



D. COLLECTOR VEHICLE DETAILS

If you have more than 3 Collector vehicles, use additional forms to complete the application.

YEAR MAKE MODEL BODY STYLE VIN VALUE DATE PURCHASED

Veh. 1

Veh. 2

Veh. 3

STORAGE TYPE* STORAGE LOCATION: If different than mailing or

garaging address above. Please include County.

Is the Collector Vehicle currently

In your possession? LIST LIENHOLDER / FINANCED OR LEASED

Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No

*Storage type is: Enclosed Garage, Carport, Driveway, Self-storage, Common Garage or Other. If other, please explain below:

Are any of the above listed vehicles owned, titled or registered to someone other than the applicant? YES NO

IS VEHICLE

MODIFIED OR

CUSTOMIZED?

CONDITION OF THE COLLECTOR VEHICLE

Veh. 1 Yes No Excellent Very Good Good Under restoration* Odometer Reading:



*If the vehicle is under restoration please provide details such as who’s doing the work and the amount of time before the vehicle will be complete.

E. VEHICLE USAGE Please specify the usage for each vehicle (check all that apply)

Hobby Related

Activities

(I.e. Car shows & car

club events)

Visiting

Friends or

Family

Exercising

the motor

Occasional General

Transportation

(I.e. Running errands &

trips to work)

Timed or Racing

Events

Driver’s Education Events

OTHER* ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3

* If the vehicle is used for a reason not listed above please describe: ___________________________________________________________________

F. COVERAGES

Please note that the liability coverage purchased from us cannot exceed the limits of your regular use vehicles. PLEASE SELECT THE LIMIT OF

COVERAGE DESIRED BELOW. All policies must include Other Than Collision Coverage.

BODILY INJURY & PROPERTY DAMAGE LIABILITY

[ $20,000/40,000/5,000] [ $50,000/100,000/25,000] [ $100,000/300,000/50,000]

[ $250,000/500,000/100,000] [ $300,000/500,000/100,000] DECLINE COVERAGE

BASIC PERSONAL INJURY PROTECTION Medical Expense

[ $8,000]

MEDICAL PAYMENTS [ $5,000] [ DECLINE COVERAGE]

UNINSURED AND UNDERINSURED MOTORIST COVERAGES

Please refer to the Massachusetts Uninsured/Underinsured Motorist Basic and Increased Limits

Selection Form (A1028APC) for available coverage limits. Please complete, sign and attach the form

to this application.

OTHER THAN COLLISION DEDUCTIBLE $300 $500 $1,000 $2,500 $5,000 [ __________ ]

COLLISION DEDUCTIBLE $300 $500 $1,000 $2,500 $5,000

[ ___________ ] DECLINE COVERAGE

TOWING & LABOR FOR COLLECTORS (TLC) PLAN - TLC is a reimbursement

based emergency Roadside assistance plan specific for Collector Cars. If you

would like to learn more about this affordable plan call us at (800) 360-2277.

SILVER PLAN ($9.95) GOLD PLAN ($24.95)

PLATINUM PLAN ($34.95) DECLINE COVERAGE

INCREASED SPARE PARTS COVERAGE

Coverage for additional spare parts that belong on the collector vehicle.

$500 is included at no cost. Additional limits are available in $500 increments

Provide me with additional coverage for $_____________ of Spare Parts.



[$100.00] Minimum Written Premium

G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience. Vehicles with anti-theft devices or passive restraint devices. Please contact New Hampshire

Insurance Company for additional details.

H. IMPORTANT NOTICES & FRAUD WARNING

NOTICE OF INSURANCE INFORMATION PRACTICES

CONSUMER REPORTS

A consumer report about you or other individuals listed as policyholders, drivers or household members (e.g.

driving record, claims history) may be requested in connection with this application, policy amendments and/or

renewals. This consumer report information which we have or may obtain will be treated confidentially and will

not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by

law.

OTHER NON-PUBLIC PERSONAL INFORMATION

Information contained in this application and any additional non-public personal information subsequently

collected, will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or

required by law.

YOUR RIGHTS

You have the right to see personal information collected about you, and you have the right to correct any

information which may be wrong. You may obtain a more detailed description of our information practices and

your rights regarding information we collect by viewing our privacy policy online at

www.NewHampshireInsuranceCompany.com, calling New Hampshire Insurance Company, or, if you have

been issued a policy, you may write us at the address provided with your policy.

FRAUD WARNING

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance or statement of claim containing any materially false information or conceals,

for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance

act, which is a crime and may subject such person to criminal and civil penalties.

I. TERMS & CONDITIONS - PLEASE READ BEFORE SIGNING

Limitations of Use-Insured vehicle(s) may be used for hobby activities and pleasure drives. Pleasure drives

do not include general or daily type transportation. Only under the Freedom Tier option with a mileage

limitation of 7,500 is occasional general use acceptable (subject to state availability). Collector vehicles insured

with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These

vehicles may not be used for any timed, racing or Driver’s Education events. Annual mileage may not exceed

the mileage tier you purchased (refer to your policy binder or declarations page). Vehicle(s) must be kept in a

completely enclosed, locked garage when not in use; unless an alternate garaging situation has been approved

by New Hampshire Insurance Company (subject to state availability).

Acknowledgements

1. The information provided to complete the application was provided by me and, to the best of my

knowledge, is accurate and true.

2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire

Insurance Company.

3. The collector vehicle(s) insured by New Hampshire Insurance Company is or will be titled in my name only

(or myself and my spouse) and will remain as such. Furthermore, I will advise New Hampshire Insurance

Company of any changes in the named insured.



4. I acknowledge that the collector vehicle(s) does not currently have any unrepaired damage and further

understand that New Hampshire Insurance Company is not responsible for any damage that was sustained

to the insured vehicle(s) prior to the issuance of this policy.

5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy) may operate any vehicle insured by New Hampshire Insurance

Company.

6. Our policies are subject to a non-refundable, minimum earned premium of $50.00.

7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of

each collector vehicle within 20 days. Any photograph will become property of New Hampshire Insurance

Company and will not be returned.

APPLICANT’S STATEMENT

I acknowledge that I have read and understood this application in its entirety and agree with all terms and

conditions set forth under this application. I agree that this application and any materials submitted by me or on

my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically

attached to the policy or not. Failure to comply with any of the above terms and conditions may result in

coverage being denied.

PROPOSED

EFFECTIVE DATE

APPLICANT’S SIGNATURE

x

DATE

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING THIS APPLICATION AND ANY

SUBSEQUENT SERVICE NEEDS?

Phone or Email

M3756MAMC-0316 © American International Group, Inc. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc.,


ANTIQUE MOTORCYCLE INSURANCE APPLICATION – MASSACHUSETTS







PLEASE LIST ANY COLLECTOR MOTORCYCLE CLUBS THAT YOU BELONG TO:

IS THE COLLECTOR MOTORCYCLE CURRENTLY INSURED WITH ANOTHER COMPANY? IF YES, INDICATE COMPANY:

Yes No


NAME DATE OF

BIRTH

RELATIONSHIP


YEARS

LICENSED

OPERATES

COLLECTOR

MOTORCYCLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household

Member 3

Yes No Yes No

Household

Member 4

Yes No Yes No



COMPANY

PROVIDED

VEHICLE?



LIABILITY (EX. 100/300) UM/UIM (EX. $100/300)

#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD



Applicant Yes No

Household

Member 2 Yes No

Household

Member 3 Yes No

Household

Member 4 Yes No

PRODUCER # ____________________

QUOTE #________________________



D. COLLECTOR MOTORCYCLE DETAILS

If you have more than 3 Collector motorcycles, use additional forms to complete the application.

YEAR MAKE MODEL CYCLE TYPE CC’s VIN VALUE DATE PURCHASED

Veh. 1

Veh. 2

Veh. 3



Is the Collector Motorcycle currently


Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No


Are any of the above listed motorcycles owned, titled or registered to someone other than the applicant? YES NO

IS MOTORCYCLE

MODIFIED OR

CUSTOMIZED?

CONDITION OF THE COLLECTOR MOTORCYCLE




*If the motorcycle is under restoration please provide details such as who’s doing the work and the amount of time before the motorcycle will be complete.

E. MOTORCYCLE USAGE Please specify the usage for each motorcycle (check all that apply)

Hobby Related

Activities


club events)

Visiting Friends or

Family Exercising the motor

Occasional General

Transportation


trips to work)

Timed or Racing

Events OTHER*

ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3

* If the motorcycle is used for a reason not listed above please describe: ________________________________________________________________

F. COVERAGES



BODILY INJURY & PROPERTY DAMAGE

LIABILITY [ $20,000/40,000/5,000] DECLINE COVERAGE

PEDESTRIAN PERSONAL INJURY

PROTECTION – Medical Expense [ $8,000]

UNINSURED AND UNDERINSURED

MOTORIST COVERAGES Please refer to the Massachusetts Uninsured/Underinsured Motorist Selection Form (A1028APC) for

available coverage limits. Please complete, sign and attach the form to this application.

OTHER THAN COLLISION DEDUCTIBLE $300 $500 $1,000 $2,500 $5,000 [ _______ ]

COLLISION DEDUCTIBLE $300 $500 $1,000

$2,500 $5,000 [ _______ ] DECLINE COVERAGE


based emergency Roadside assistance plan specific for Collector Motorcycles. If you would like to learn more about this affordable plan call us at (800) 360-2277.

SILVER PLAN ($9.95) DECLINE COVERAGE


Coverage for additional spare parts that belong on the collector motorcycle.






G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving

experience and collector motorcycles with anti-theft devices. Please contact New Hampshire Insurance

Company for additional details.



CONSUMER REPORTS

A consumer report about you or other individuals listed as policyholders, drivers or household members (e.g.

driving record, claims history) may be requested in connection with this application, policy amendments and/or

renewals. This consumer report information which we have or may obtain will be treated confidentially and will

not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by

law.

OTHER NON-PUBLIC PERSONAL INFORMATION

Information contained in this application and any additional non-public personal information subsequently

collected, will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or

required by law.

YOUR RIGHTS

You have the right to see personal information collected about you, and you have the right to correct any

information which may be wrong. You may obtain a more detailed description of our information practices and

your rights regarding information we collect by viewing our privacy policy online at

www.NewHampshireInsuranceCompany.com, calling New Hampshire Insurance Company, or, if you have

been issued a policy, you may write us at the address provided with your policy.

FRAUD WARNING

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person

files an application for insurance or statement of claim containing any materially false information or conceals,

for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance

act, which is a crime and subjects such person to criminal and civil penalties.


Limitations of Use-Insured motorcycle(s) may be used for hobby activities and pleasure drives. Pleasure

drives do not include general or daily type transportation. Collector motorcycles insured with New Hampshire

Insurance Company cannot be used as a substitute for your daily use collector motorcycle. These motorcycles

may not be used for any timed or racing events. Annual mileage may not exceed the mileage tier you

purchased (refer to your policy binder or declarations page). Motorcycle(s) must be kept in a completely

enclosed, locked garage when not in use; unless an alternate garaging situation has been approved by New

Hampshire Insurance Company (subject to state availability).

Acknowledgements

1. The information provided to complete the application was provided by me and, to the best of my

knowledge, is accurate and true.

2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire

Insurance Company.

3. The collector motorcycle(s) insured by New Hampshire Insurance Company is or will be titled in my name

only (or myself and my spouse) and will remain as such. Furthermore, I will advise New Hampshire

Insurance Company of any changes in the named insured.



4. I acknowledge that the collector motorcycle(s) does not currently have any unrepaired damage and further

understand that New Hampshire Insurance Company is not responsible for any damage that was sustained

to the insured motorcycle(s) prior to the issuance of this policy.

5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy) may operate any motorcycle insured by New Hampshire

Insurance Company.

6. Our policies are subject to a non-refundable, minimum earned premium of $50.00.

7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of

each collector motorcycle within 20 days. Any photograph will become property of New Hampshire

Insurance Company and will not be returned.


I acknowledge that I have read and understood this application in its entirety and agree with all terms and

conditions set forth under this application. I agree that this application and any materials submitted by me or on

my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically

attached to the policy or not. Failure to comply with any of the above terms and conditions may result in

coverage being denied. PROPOSED EFFECTIVE DATE


x DATE

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING THIS APPLICATION AND ANY

SUBSEQUENT SERVICE NEEDS?

Phone or Email

MASSACHUSETTS INSURANCE IDENTIFICATION CARD

(STATE)

COMPANY NUMBER COMPANY

POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE

YEAR MAKE / MODEL VEHICLE IDENTIFICATION NUMBER

AGENCY / COMPANY ISSUING CARD

SEE IMPORTANT NOTICE ON REVERSE SIDE

INSURED

ID0001-0316

ID0001-0316 © American International Group, Inc. All rights reserved.Includes copyrighted material of Insurance Services Office, Inc.,


Page 1 of 2

THIS CARD MUST BE KEPT IN THE INSUREDVEHICLE AND PRESENTED UPON DEMAND

IN CASE OF ACCIDENT:

1. Contact the local authorities immediately.2. Obtain the name, address, & phone number for each driver,

passenger, and witness.3. Obtain the name of the insurance company and policy number for

each vehicle involved.4. Report the accident to New Hampshire Insurance Company at your

earliest convenience.

To report a claim or for Customer Service call our toll-free number:

(800) 360-2277



Page 2 of 2

PERSONAL AUTOPP 13 01 12 99


PP 13 01 12 99 Copyright, Insurance Services Office, Inc., 1999 Page 1 of 1

COVERAGE FOR DAMAGE TO YOUR AUTO EXCLUSION ENDORSEMENT

With respect to the coverage provided by this endorsement, the provisions of the policy apply unless modified bythe endorsement.

I. Definitions


"Diminution in value" means the actual or per-ceived loss in market or resale value which resultsfrom a direct and accidental loss.

II. Part D – Coverage For Damage To Your Auto

The following exclusion is added:

We will not pay for:

Loss to "your covered auto" or any "non-ownedauto" due to "diminution in value".

This endorsement must be attached to the Change Endorsement when issued after the policy is written.

PERSONAL AUTOPP 03 10 08 86

PP 03 10 08 86 Copyright, Insurance Services Office, Inc., 1986 Page 1 of 1

CHANGE ENDORSEMENT

Attached to and forming part of:

Policy No.

of the (Insurance Co.)

Insured

Address (as shown on Policy)

Effective Date of Endorsement(s):

Term of Policy from: to:

Agency

By:

Endorsement Number(s):

----------------------------------------------------Attach Endorsements Below This Line-----------------------------------------------

AB#AA#MA-0317 © American International Group, Inc. All rights reserved. Page 1 of 31 Includes copyrighted material of Insurance Services Office, Inc.,


NEW HAMPSHIRE INSURANCE COMPANY

ANTIQUE AUTO MANUAL MASSACHUSETTS

FORMS

Form Number Description ISO Forms: PP 00 01 01 05 Personal Auto Policy PP 05 75 04 12 Personal Injury Protection Coverage Massachusetts PP 13 01 12 99 Coverage for Damage to Your Auto Exclusion PP 03 10 08 86 Change Endorsement Mandatory Forms: AJ9898JPC Policy Jacket ANA0001D Policy Declarations Page ID0001 Massachusetts Insurance Identification Card Mandatory Endorsements: AB3807EPC Amendment of Policy Provisions Massachusetts AB3808EPC Uninsured Motorists Coverage Massachusetts AB3811EPC Antique Auto Coverage Endorsement Massachusetts AB3814EPC Other Than Collision Coverage Glass Options Massachusetts AB3815EPC Collision Coverage Waiver of Deductible Massachusetts AH9675ERR Vehicle/Coverage Schedule Massachusetts PCG-OFAC Economic Sanctions Endorsement Optional Endorsements: AB1106EPC Towing and Labor Emergency Expense Reimbursement Massachusetts AB3809EPC Underinsured Motorists Coverage Massachusetts AB3810EPC Named Driver Exclusion Endorsement Massachusetts AB3825EPC Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3861EPC Increased Limits for Spare Parts Coverage Endorsement Massachusetts



ANTIQUE AUTO MANUAL MASSACHUSETTS GENERAL RULES

I. DEFINITIONS APPLICABLE TO GENERAL RULES

1. An Antique vehicle means a private passenger vehicle, which is: a. At least twenty five years old; b. Used for exhibitions; club activities, parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected. 2. A Classic vehicle means a private passenger vehicle, which is:

a. Newer than twenty five years old where the vehicle is considered to be appreciating in value and is of unique or rare design or limited production;

b. Used for exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected.

3. A Modified vehicle means a private passenger vehicle which is: a. Modified from its original specifications; b. Used for: exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 miles during an annual policy term, dependent upon the mileage tier selected. Replica or kit cars are considered Modified vehicles.

II. ELIGIBILITY

A Personal Auto Policy shall be used to afford coverage to Antique motor vehicles as described in Rule I. if: 1. they are written on a specified auto basis; and 2. they are owned by an individual or by his or her spouse who are residents of the same household.

III. PREMIUM DETERMINATION

Bodily Injury Liability, Property Damage Liability, Medical Payments, Personal Injury Protection, Agreed Value Other than Collision

and Collision premiums are determined in the following manner: A. Refer to the Rate Pages to determine the rate for Split Limit Liability for the limit liability selected and number of motor

vehicles to be insured. B. Refer to the State Rate Pages to determine the rate for Medical Payments depending on the number of motor vehicles to

be insured. C. Refer to the State Rate Pages to determine the rate for Uninsured and/or Underinsured Motorist Coverage depending on

the limit of liability selected and the number of motor vehicles to be insured. D. Refer to the State Rate Pages to determine the rate for Agreed Value Other than Collision or Agreed Value Collision and

Other than Collision (Physical Damage) coverages. Multiply the rate from the State Rate Pages by the amount of coverage desired (expressed in hundreds of dollars) to determine the premium. For any single vehicle policy where the vehicle is less than $10,000, use the Low Value Relativity Factor to determine the final premium.

E. Refer to the State Rate Pages, or State Exception Pages, to determine the cost of any additional state specific fees or coverages.

F. Refer to Section X: Surcharges and Discounts to determine any applicable discounts/surcharges applicable to the individual coverages above.

IV. MINIMUM PREMIUM RULE A. The minimum written premium charge for all coverages combined shall be $100. B. This minimum annual premium charge is not subject to reduction.




V. POLICY PERIOD The policy term will be 12 months. VI. CHANGES A. All changes requiring premium adjustments shall be computed pro rata. B. Adjustment of $5 or less: 1. If a policy is amended, and results in an additional premium adjustment of $5 or less, the amount shall be waived. 2. Minimum premium of $5 applies if an insured requests the following during the policy period: a. Additional coverage, b. An increase in the limits of liability. 3. Company need not refund a return premium of less than $5 if the insured requests the following: a. Cancellation of coverage, b. Reduction of limits of liability, c. Increase in deductible except that the actual return premium shall be returned at the request of the insured. 4. If the limits of liability are increased because of a change in the limits prescribed under the Massachusetts financial

responsibility law, the additional premium charge shall be the actual difference in premium charges. VII. CANCELLATION AND NON-RENEWAL CANCELLATION A. If a policy, vehicle or form of coverage is cancelled: 1. by the Company, the return premium will be computed on a pro rata basis; 2. by the insured: a. for 12 month policy periods, compute the return premium at 90% of the pro rata unearned premium for one year,

subject to the minimum earned of $50. b. Exception – The return premium will be computed on a pro rata basis in the following cases: i) The insured cancels the policy within the first 30 days from the date on which the policy becomes effective or

the date on which the insured receives the policy documents, whichever is later. ii) The insured cancels the policy within 30 days after the date on which the insured motor vehicle is stolen or

destroyed, if the loss to the motor vehicle is a total loss or total constructive loss; or, within 15 days of the time the auto was determined by the Company to be: (a) uncoverable if stolen; or (b) to be a total or constructive loss. The return premium, if any, shall be calculated from the day following the date of loss.

iii) The insured cancels the policy because of entry into the military service of the United States of America. iv) The insured cancels a policy issued through the Massachusetts residual market plan (if applicable) because

coverage has been obtained in the voluntary market. v) If the insured has disposed of the insured vehicle and takes out a new policy with the Company on another

vehicle to become effective within 30 days of the date of cancellation. vi) In a multi-vehicle situation:

a) If one vehicle is cancelled from the policy and the policy remains in force on the other vehicle(s); or b) If a policy is cancelled and there remains in force with the same Company in the name of the insured or

spouse a concurrent policy covering another vehicle. vii) If a vehicle or form of coverage is cancelled from a policy and the policy remains in force.

3. A minimum earned premium of $50 will be retained in all cases, except flat cancellations. 4. Any return premium associated with the unexpired portion of the term of the cancelled policy shall be delivered to the

insured within 30 days of the effective date of cancellation. 5. The Company is required to notify the MA Registrar of Motor Vehicles of the cancellation of a motor vehicle policy,

whether initiated by the Company or the insured, in accordance with the procedures prescribed by the Registrar. If a policy is reinstated after issuing a notice of cancellation, the Company must notify the Registrar of that fact.




VII. CANCELLATION AND NON-RENEWAL (continued) B. How to use Pro Rata Table 1. Express the date of the cancellation by year and decimal part of a year by combining the calendar year with the decimal

appearing opposite the month and day in the Pro Rata Table, for example April 2, 1996 would be expressed as 1996.252. 2. In a like manner, express the effective date of the policy by year and decimal part of a year and subtract from the

cancellation date. 3. The difference represents the percentage of the annual premium which is to be retained by the Company. Example: Cancellation date of September 26, 2000 2000.737 Effective date of April 2, 2000 2000.252 0.485 Earned premium for a 12 month policy will therefore be .485 times the annual premium. Note: As it is not customary to charge for the extra day that occurs every four years (February 29), the Pro Rata Table will

also be used for each such year. NON-RENEWAL A. The Company is also required to send notice of nonrenewal to the MA Registrar of Motor Vehicles at least 45 days prior to the

expiration of the policy in accordance with the Registrar’s procedures. If the Company reinstates a policy after issuing a notice of nonrenewal it must notify the Registrar of Motor Vehicles of such reinstatement.

B. If the Company sends a non-renewal notice and then subsequently renews the policy, it must, at the insured’s request, issue insurance coverage of at least the same type and amount as existed on the nonrenewed policy.

VIII. REMOVAL OF COVERAGE At the request of the named insured, all coverage except for Other than Collision coverage will be removed. Exception: coverage will not be removed every year due to winter storage. IX. OPTIONAL ENDORSEMENTS A. Named Driver Exclusion Endorsement Massachusetts 1. Availability of a Named Driver Exclusion Endorsement

A motor vehicle liability policy may contain a Named Driver Exclusion Endorsement. If so, the Named Driver Exclusion Endorsement must specifically designate by name the individual or individuals to be excluded.

2. Additional Requirements a. The named insured and the excluded driver must acknowledge, in writing, the Named Driver Exclusion

Endorsement. b. The Named Driver Exclusion Endorsement should designate each vehicle under the policy where the named

excluded driver shall not be covered under the policy.

3. Endorsement: Attach Named Driver Exclusion Endorsement Massachusetts AB3810EPC.

B. Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts

This endorsement is offered as an option to the named insured to provide coverage for antique motorcycles and amends the

definition of "your covered auto" to include motorcycle. Refer to Rate Pages Antique Motorcycle 2500 Mile Tier.

Attach Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3825EPC.




IX. OPTIONAL ENDORSEMENTS (continued) C. Towing and Labor Emergency Expense Reimbursement Massachusetts This optional endorsement provides increased Towing and Labor reimbursement coverage, in addition to reimbursement for

other emergency roadside assistance options based on the plan selected. Coverage is provided for all vehicles listed on the Policy Declarations Page.

1. Silver Plan a. $100 Emergency Towing b. $50 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service 2. Gold Plan a. $150 Emergency Towing b. $100 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service e. $250 Emergency Travel Expense f. $2,500 Theft Reward g. $250 Personal Effects h. $100 Ambulance Assistance i. $100 Car Show Expenses 3. Platinum Plan a. $250 Emergency Towing b. $150 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service e. $500 Emergency Travel Expense f. $5,000 Theft Reward g. $500 Personal Effects h. $250 Ambulance Assistance i. $150 Car Show Expenses j. $5,000 Bail Bond k. $1,000 Legal Defense Benefit l. $1,000 Hit and Run Reward m. TrailerGuard $150 each disablement

Antique/Classic and Modified Vehicles are eligible for the Silver, Gold and Platinum Plans. Antique Motorcycles are only eligible for the Silver Plan.

Attach Towing and Labor Emergency Expense Reimbursement Endorsement Massachusetts AB1106EPC. Refer to State Rate Pages for Rates.

D. Increased Limits For Spare Parts Coverage Endorsement Massachusetts

We will pay up to $500 for direct and accidental loss to spare parts and accessories to “your covered auto”. Base limit of $500 may be increased for an additional premium.

Attach Increased Limits For Spare Parts Coverage Endorsement Massachusetts AB3861EPC if additional limits are selected. Refer to State Rate Pages for additional premium.




X. SURCHARGES & DISCOUNTS

A. Garaging Surcharge

Vehicles that are written with underwriting approval that are not maintained in a fully enclosed locked private garage are subject to a

surcharge on the Other than Collision coverage. Refer to State Rate Pages for the surcharge amount.

B. Inexperienced Operator Surcharge

Drivers with at least (5) years of driving experience, but less than (10) years who meet the Inexperienced Operator Guidelines are

eligible for the program; however, a surcharge will apply to the highest rated vehicle on the policy. The surcharge is applicable to all coverages. Refer to State Rate Pages for the surcharge amount.

C. Car Club Discount Drivers who are active members of a car club approved by the Division of Insurance with a minimum of one thousand (1000)

members are eligible to receive a discount for their policy. Refer to State Rate Pages for the discount amount. D. High Value Discount Insureds that have a single eligible collector vehicle valued greater than $250,000 or have a collection of two or more eligible collector

vehicles with a total value greater than $250,000 are eligible to receive a discount on Other than Collision and Collision coverage. Refer to State Rate Pages for the discount amount.

E. Multiple Policy Discount Insureds who maintain an active Collectibles policy under New Hampshire Insurance Company are eligible for a premium discount.

The discount is applicable to all coverages. Refer to the State Rate Pages for the discount amount. F. Multiple Vehicle Policy Discount Insureds that have a policy with more than one vehicle are eligible to receive a premium discount. The discount is applicable to the

Collision and Other than Collision coverages. Refer to the State Rate Pages for the discount amount. G. Affinity Discount Insureds who maintain an active policy with an approved insurance partner and/or has an affiliation with an approved marketing

group are eligible to receive a premium discount. This discount is applicable to all coverages. Refer to the State Rate Pages for the discount amount.




X. SURCHARGES & DISCOUNTS (continued) H. Collection Risk Modification (CRM) Discount Insureds that have a collection of two or more eligible collector vehicles with a total value greater than $250,000 are eligible to receive

discounts applicable only to Other than Collision and Collision coverage based on the following factors: A. Security – The following discounts are available for a collection located in a garage with the following security features:

Refer to State Rate Pages for the discount amount. 1. Automatic Sprinklers – A discount applies if an automatic sprinkler system is installed in the garage where the

insured vehicles are kept. 2. Central Fire Alarm – A discount applies if a central fire alarm is installed and actively working in the garage where

the insured vehicles are kept. 3. Central Burglary Alarm – A discount applies if a central burglary alarm is installed and actively working in the garage

where the insured vehicles are kept. B. Construction Grade – A discount applies for a collection located in a garage with the following construction types: Refer

to State Rate Pages for the discount amount. 1. FIRE RESISTIVE – A discount applies to garages constructed of any combination of the following materials: Exterior Walls or Exterior Structural Frame • Solid Masonry, including reinforced concrete • Hollow Masonry less than 12” thick • Hollow Masonry less than 12”, but not less than 8” thick, with a fire resistance rating of not less than 2

hours Floors and Roof • Monolithic floors and roof of reinforced concrete with slabs that are at least 4” thick • “Joist Systems” with slabs supported by concrete joists spaced no more than 36” on centers with a slab

thickness of not less than 2 ¾”. • Floor and roof assembles with a fire resistance rating of not less than 2 hours. Structural Metal Supports • Horizontal and Vertical load bearing protected metal supports with a fire resistance rating of not less than

2 hours.

2. MODIFIED FIRE RESISTIVE – A discount applies to garages with exterior walls, floors and roof constructed of masonry materials that are listed as fire resistive materials, but deficient in thickness; or fire resistive materials that are listed as fire resistive, but with a fire resistive rating of less than 2 hours, but not less than 1 hour.

3. MASONRY NON-COMBUSTIBLE – A discount applies to garages with exterior walls of fire resistive

construction or of masonry, and with non-combustible or slow burning floors and roof. 4. NON-COMBUSTIBLE – A discount applies to garages with exterior walls, floors and roof of non-

combustible or slow burning material supported by non-combustible or slow burning supports. 5. JOINTED MASONRY – No discount is applicable to garages with exterior walls of fire resistive construction

of masonry and with combustible floors and roof. 6. FRAME – No discount is applicable to garages with exterior walls, floors and roof of combustible construction

or buildings with exterior walls of non-combustible or slow burning construction, with combustible floors and roof.

C. Spread of Risk – Discounts are available for a collection which is dispersed between a minimum of two locations. Refer to

the State Rate Pages for the discount amount.




X. SURCHARGES & DISCOUNTS (continued)

I. Senior Principal Operator(s) Discount A discount is applicable to the total policy premium. A principal operator must be 65 years or older. There must not be any

operators with less than 10 years driving experience for this discount to apply. Refer to the State Rate Pages for the discount amount.

J. Passive Restraint Devices Discount A discount applies to Personal Injury Protection, Uninsured and Underinsured Motorists and Medical Payments coverage for

Antique vehicles equipped with air bags and/or automatic seat belts. Refer to the State Rate Pages for the discount amount. K. Anti-Theft Devices – Discounts apply to Other than Collision coverage only. Vehicles equipped with Anti-Theft Devices as defined below are entitled to a discount. See Rate Pages for discount amount. Definitions: “Passive” describes an anti-theft or system which is activated automatically when the operator turns the ignition key to the off

position. “Alarm”, except where otherwise specified, means horn, bell, siren or other sounding device which is audible at 300 feet. Note: The Company may require reasonable evidence of installation of any anti-theft device but may not refuse to grant a

discount to a qualifying device solely on the grounds that it was installed by the owner of the auto. 1. Steering Column Armored Collar

This device is similar to an oversized padlock which clamps on to the steering column over the ignition lock and prevents

access to it. This device, when locked prevents the vehicle from being started or if the vehicle is hot-wired and started, this device prevents it from being steered. When not in use, this device does not attach to the steering column.

2. Steering Wheel Removal Lock

This device prevents steering movement of the vehicle from a parked position. This is a high security steering wheel lock assembly manufactured of hardened steel components, which allows removal of the steering wheel from the vehicle. The assembly is permanently attached to the vehicle’s steering column and is located between the column and the steering wheel. Operation of the lock is controlled by a high security configured key. Unlocking the assembly will permit removal of the steering wheel from the vehicle. A fitted security plate is then inserted onto the lock assembly in place of the steering wheel and the locks, security key is then removed. Re-attachment of the steering wheel onto the lock assembly requires use of the security key to first remove the fitted security plate and then to attach the steering wheel. The security key can be removed from the lock assembly only after either the security plate or steering wheel has been locked into place.

3. Ignition or Starter Cut-off Switch in Combination with Flush or Tapered Door Lock Buttons

This device is an ignition cut-off switch (a.k.a. “kill-switch”) or a starter cut-off switch is inserted into the ignition wiring of an auto. The switch is tripped when leaving the auto and must be switched back in order to start the auto.

The switch must be installed so that it is not visible from the driver’s position when the driver is seated. In addition, the

vehicle must contain flush or tapered door lock buttons on all doors. A sticker may be used to identify the system.

4. Ignition or Starter Cut-off Switches

This ignition or starter cut-off switches either must be designed so that the wires leading from the switch to the engine compartment are protected by armored tubing or cable, or operate passively.

5. Non-Passive, Externally-Operated Alarm

This is a non-passive warning alarm which is installed in the auto and can be set to go off if any door, the trunk or the hood is opened without first turning off the alarm by inserting a key into a lock mounted on the outside of the auto.




X. SURCHARGES & DISCOUNTS (continued) Vehicles equipped with the following devices are entitled to a discount. See Rate Pages for discount amount. 1. Window Identification System A window identification system is one which identification letters and/or numbers are etched by sandblasting, chemical

process or other permanent marking into all windows of the vehicle other than the small vent windows. Provisions must be made for immediate telephone identification of the owner of the vehicle any time of day or night.

2. Car Transmission Lock This device prevents the vehicle from moving from a parked position by locking the gear shift. A steel-encased lock is

permanently attached to the floor of the vehicle by a steel stand. The shackle, made of case hardened alloy steel, fits around the gear shift and is inserted into the lock. The device must have a high security locking system with at least 50,000 combinations. The lock, shackle and stand must resist cutting and filing.

Vehicles equipped with the following devices are entitled to a discount. See Rate Pages for discount amount. 1. Passive Alarm System. This alarm must meet the following criteria: a. Ignition must be cut off automatically, or starter must be disabled automatically. b. Alarm must be triggered by entry of doors, hood or trunk. c. Hood must not open unless unlocked from inside the vehicle by a key, or by an electronic keyless device. d. Alarm must sound for no more than eight minutes and upon ceasing to sound must reset itself. e. Alarm must not emit a pulsating, whooping, or yelping sound which would cause it to be mistaken for the modern

police, fire or other emergency vehicle siren. f. Alarm must be installed in the engine compartment so as to be inaccessible without opening hood. g. The system must be engaged passively by turning the ignition key to the off position. To disarm the system a tubular

lock or electronic keyless device must be used. The maximum time delay permitted to disarm the system after re-entry is 20 seconds.

2. Passive Fuel Cut-Off Device. This fuel cut-off device is engaged by turning the ignition key to the off position. The driver

must trip a switch to open the fuel line each time the vehicle is started. This device must meet the following criteria: a. The fuel line must be blocked when the power is off. b. Switch to open fuel line must be well hidden from view, but accessible to the driver from the driver’s seat. In the

alternative a tubular key or an electronic keyless device may be used. c. A parking/service attendant override switch may be provided. It must be well hidden from view. It must not be

accessible from the passenger compartment, alternatively, if the override switch is accessible from the passenger compartment, a warning buzzer must sound (or the operator must be distracted in some other way) while the engine is running and the override switch engages. If the buzzer is disconnected, it must result in disconnection of the entire anti-theft system.

d. Any under-the-dash wiring installed in connection with this device must blend in color with factory-installed wiring. 3. Passive Ignition Lock Protective System This is a casehardened steel, protective cap which fits over the ignition lock so as to prevent extraction of the ignition lock

cylinder. The cap fastens to a steel collar which fits around the steering post and over the ignition lock. A sticker may be used to identify the system.

4. Vehicle Recovery System This is an electronic unit installed in a vehicle that is activated after that vehicle is stolen. When activated, the device provides

information to law enforcement officials or another public or private entity regarding the vehicle’s location. The system provides for the routine delivery of the information to the appropriate law enforcement organization to assist in the recovery of the vehicle.

Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the device

meeting the standards for the highest discount.




XI. MISCELLANEOUS Personal Injury Protection - $8,000 Medical Expense Limit Any eligible motor vehicle rated in accordance with these rules shall be afforded Personal Injury Protection coverage as prescribed by

Massachusetts. PIP coverage cannot be rejected. Personal Injury Protection has a Medical Expense Limit of $8,000 ($2,000 maximum if other health/disability insurance is in force). It

includes: -Work Loss up to 75% of average weekly wage; (subject to $8,000/per aggregate limit) -Essential Services subject to maximum of $8,000/person -Funeral Expenses are included in Medical Exception Basic PIP benefits do not apply to Antique Motorcycles or other similar vehicles designed to travel on fewer than four wheels.

However, Pedestrian Personal Injury Protection will be afforded to pedestrians if struck by an insured motorcycle. Deductibles Personal Injury Protection has a $0 Deductible. Optional deductibles are available for a reduction in PIP premium. See Rate Pages for

discount factors. Our total payment for medical expenses, lost wages and replacement services will not exceed $8,000

Attach Personal Injury Protection Coverage Massachusetts PP 05 75 Uninsured Motorists Coverage This form of auto insurance must be afforded at limits not less than the financial responsibility limits under every auto liability policy

issued to the owner of a motor vehicle registered or principally garaged in Massachusetts. If Uninsured Motorists Coverage is afforded, it shall apply to all vehicles insured on the policy. Increased Limits Increased limits Uninsured Motorists Insurance may be offered up to the policy’s Split Limit Liability limits, subject to a maximum of

$500,000/500,000. Exceptions The named insured may reject increased limits, but not the minimum limit coverage of $20,000/40,000, in writing. If the named

insured fails to communicate this election, in writing, the increased limits are presumed to be selected.

Attach Uninsured Motorists Coverage Massachusetts - AB3808EPC Underinsured Motorists Coverage This form of coverage shall be offered as an option to the insured at limits up to the Split Liability limits of the policy. When

Underinsured Motorists Coverage is afforded, it must apply to all vehicles insured under the policy. Exceptions The named insured has the right to reject the Underinsured Motorists Coverage in writing. If the named insured fails to communicate

this election, in writing, the coverage is presumed to be selected. Medical Payments This form of coverage shall be offered at a limit of $5,000 per person under every auto liability policy. It will be afforded at the option

of the named insured. Motorcycles Antique Motorcycles are eligible only for Pedestrian Personal Injury Protection coverage with a $0 deductible. Bodily Injury Liability coverage does not apply to owners or guest passengers of an insured motorcycle.

Attach Underinsured Motorists Coverage – Massachusetts -AB3809EPC



ANTIQUE AUTO MANUAL MASSACHUSETTS RATE PAGES

I. PERSONAL INJURY PROTECTION – OPTIONAL DEDUCTBLES

Personal Injury Protection has a $0 Deductible. Optional deductibles are available for a reduction in PIP premium. Multiple the base PIP premium by the discount factor for the selected deductible option below.

Deductible Amount Discount Factor

$100 0.92 $250 0.85 $500 0.80

$1,000 0.72 $2,000 0.64 $4,000 0.50 $8,000 0.17

II. SURCHARGES & DISCOUNTS Garaging Surcharge

Vehicles that are written with underwriting approval that are not maintained in a fully enclosed locked private garage are subject to a surcharge on the Other than Collision coverage. Please select the appropriate surcharge factor based off the garaging type below. Multiply the factor against the calculated premium charge for Other than Collision coverage.

GARAGE TYPE SURCHARGE FACTOR

Commercial Self Storage Unit 1.30

2/3 Walled Carport or Private Common Garage 2.00

Trailers (with wheels) 3.00

Inexperienced Operator Surcharge

Drivers with at least 5 years of driving experience, but less than 10 years who meet the Inexperienced Operator Guidelines are eligible for the program; however, a 2.0 surcharge factor will apply to the highest rated vehicle on the policy. This surcharge is applicable to all coverages.

Car Club Discount

A 5% discount applies, to the premiums for all coverages, when the insured is an active member of a car club approved by the Division of Insurance that has a minimum of one thousand (1,000) members.

High Value Discount

A 20% discount applies to the premiums for Agreed Value Other than Collision and Agreed Value Collision when the insured has a single vehicle valued greater than $250,000 or a collection of two or more vehicles with a total value greater than $250,000.

Multiple Policy Discount

A 3% discount is applied to any insureds who maintain an active Collectibles policy under New Hampshire Insurance Company. The discount is applicable to all coverages.

Multiple Vehicle Policy Discount

Insureds that have a policy with more than one vehicle are eligible to receive a premium discount. Select the discount factor below applicable to an individual vehicle based on the total number of vehicles on the policy and the model year of the individual vehicle. Multiply the selected discount factor against the individual vehicle's calculated premium for Other than Collision and Collision coverage to determine the discount.

Vehicle Model Year 2 Vehicle Policy More than 2 vehicles on Policy

Prior to 1988 10% Discount 15% Discount

1988 and Newer 3% Discount 6% Discount




II. SURCHARGES & DISCOUNTS (continued) Affinity Marketing Partner Discount

A 5% discount is applied to any insured who maintains an active policy with an approved insurance partner and/or has an affiliation with an approved marketing group.

Collection Risk Modification (CRM) Discount In order for a policy to qualify for any Collection Risk Modification (CRM) discounts, the policy must contain two or more vehicles with a total collection value greater than $250,000. The CRM discounts are only applicable to the Other than Collision and Collision coverage. A. Security – The following discounts are available for a collection located in a garage with the following security features: 1. Automatic Sprinklers – A 10% discount applies if an automatic sprinkler system is installed in the garage where the insured

vehicles are kept. 2. Central Fire Alarm – A 5% discount applies if a central fire alarm is installed and actively working in the garage where the

insured vehicles are kept. 3. Central Burglary Alarm – A 5% discount applies if a central burglary alarm is installed and actively working in the garage

where the insured vehicles are kept. B. Construction Grade – The following discounts are available for a collection located in a garage with the following construction

types: 1. A 10% discount applies to garages constructed of any combination of the following materials: FIRE RESISTIVE

Exterior Walls or Exterior Structural Frame • Solid Masonry, including reinforced concrete • Hollow Masonry less than 12” thick • Hollow Masonry less than 12”, but not less than 8” thick, with a fire resistance rating of not less than 2 hours

Floors and Roof • Monolithic floors and roof of reinforced concrete with slabs that are at least 4” thick • “Joist Systems” with slabs supported by concrete joists spaced no more than 36” on centers with a slab thickness of

not less than 2¾”. • Floor and roof assemblies with a fire resistance rating of not less than 2 hours.

Structural Metal Supports • Horizontal and Vertical load bearing protected metal supports with a fire resistance rating of not less than 2 hours. MODIFIED FIRE RESISTIVE – Applicable to garages with exterior walls, floors and roof constructed of masonry

materials that are listed as fire resistive materials, but deficient in thickness; or fire resistive materials that are listed as fire resistive, but with a fire resistive rating of less than 2 hours, but not less than 1 hour.

2. A 5% discount applies to garages constructed of any combination of the following materials: MASONRY NON-COMBUSTIBLE – Applicable to garages with exterior walls of fire resistive construction or of

masonry, and with non-combustible or slow burning floors and roof. NON-COMBUSTIBLE – Applicable to garages with exterior walls, floors and roof of non-combustible or slow burning

material supported by non-combustible or slow burning supports. 3. No discount applies to garages constructed of any combination of the following materials: JOINTED MASONRY – Applicable to garages with exterior walls of fire resistive construction of masonry and with

combustible floors and roof. FRAME – Applicable to garages with exterior walls, floors and roof of combustible construction or buildings with exterior

walls of non-combustible or slow burning construction, with combustible floors and roof




II. SURCHARGES & DISCOUNTS (continued) C. Spread of Risk – The following discounts are available for a collection which is dispersed between a minimum of two locations. a. 2 Garaging Locations – 3% Discount b. 3 Garaging Locations – 6% Discount c. 4 or more Garaging Locations - 10% Discount

D. The total maximum discount allowed under parts A, B and/or C is 25%.

Senior Principal Operator(s) Discount A 25% discount is applicable to the total policy premium. A principal operator must be 65 years or older. There must not be any

operators with less than 10 years driving experience for this discount to apply. Passive Restraint Devices Discount A 25% discount applies to Personal Injury Protection, Uninsured and Underinsured Motorists and Medical Payments coverage for

vehicles equipped with air bags and/or automatic seat belts. Anti-Theft Devices Discounts The following Discounts apply to Other than Collision coverage only.

Vehicles equipped with Anti-Theft Devices as defined below are entitled to a 5% Discount:

Definitions: “Passive” describes an anti-theft or system which is activated automatically when the operator turns the ignition key to the off

position.

“Alarm”, except where otherwise specified, means horn, bell, siren or other sounding device which is audible at 300 feet.

Note: The Company may require reasonable evidence of installation of any anti-theft device but may not refuse to grant a discount to a qualifying device solely on the grounds that it was installed by the owner of the auto.

1. Steering Column Armored Collar This device is similar to an oversized padlock which clamps on to the steering column over the ignition lock and prevents access

to it. This device, when locked prevents the vehicle from being started or if the vehicle is hot-wired and started, this device prevents it from being steered. When not in use, this device does not attach to the steering column.


This device prevents steering movement of the vehicle from a parked position. This is a high security steering wheel lock assembly manufactured of hardened steel components, which allows removal of the steering wheel from the vehicle. The assembly in permanently attached to the vehicle’s steering column and is located between the column and the steering wheel. Operation of the lock is controlled by a high security configured key. Unlocking the assembly will permit removal of the steering wheel from the vehicle. A fitted security plate is then inserted onto the lock assembly in place of the steering wheel and the lock’s security key is then removed. Re-attachment of the steering wheel onto the lock assembly requires use of the security key to first remove the fitted security plate and then to attach the steering wheel. The security key can be removed from the lock assembly only after either the security plate or steering wheel has been locked into place.

3. Ignition or Starter Cut-off Switch in Combination with Flush or Tapered Door Lock Buttons.

This device is an ignition cut-off switch (a.k.a. “kill-switch”) or a starter cut-off switch which is inserted into the ignition wiring of an auto. The switch is tripped when leaving the auto and must be switched back in order to start the auto.

The switch must be installed so that it is not visible from the driver’s position when the driver is seated. In addition, the vehicle

must contain flush or tapered door lock buttons on all doors. A sticker may be used to identify the system. 4. Ignition or Start Cut-off Switches

The ignition or starter cut-off switches either must be designed so that the wires leading from the switch to the engine compartment are protected by armored tubing or cable, or operate passively.






II. SURCHARGES & DISCOUNTS (continued) Vehicles equipped with the following devices are entitled to a 15% discount: 1. Window Identification System A window identification system is one in which identification letters and/or numbers are etched by sandblasting, chemical process

or other permanent marking into all windows of the vehicle other than the small vent windows. Provisions must be made for immediate telephone identification of the owner of the vehicle any time of day or night.



Vehicles equipped with following devices receive a 20% discount: 1. Passive Alarm System. This alarm must meet the following criteria a. Ignition must be cut off automatically, or starter must be disabled automatically. b. Alarm must be triggered by entry of doors, hood or trunk. c. Hood must not open unless unlocked from inside the vehicle by a key, or by an electronic keyless device. d. Alarm must sound for no more than eight minutes and upon ceasing to sound must reset itself. e. Alarm must not emit a pulsating, whooping, or yelping sound which would cause it to be mistaken for the modern police,

fire or other emergency vehicle siren. f. Alarm must be installed in the engine compartment so as to be inaccessible without opening hood. g. The system must be engaged passively by turning the ignition key to the off position. To disarm the system a tubular lock

or electronic keyless device must be used. The maximum time delay permitted to disarm the system after re-entry is 20 seconds.

2. Passive Fuel Cut-off Device. This fuel cut-off device is engaged by turning the ignition key to the off position. The driver must

trip a switch to open the fuel line each time the vehicle is started. This device must meet the following criteria: a. The fuel line must be blocked when the power is off. b. Switch to open fuel line must be well hidden from view, but accessible to the driver from the driver’s seat. In the

alternative a tubular key or an electronic keyless device may be used. c. A parking/service attendant override switch may be proved. It must be well hidden from view. It must not be accessible

from the passenger compartment; alternatively, if the override switch is accessible from the passenger compartment, a warning buzzer must sound (or the operator must be distracted in some other way) while the engine is running and the override switch engaged. If the buzzer is disconnected, it must result in disconnection of the entire anti-theft system.




information to law enforcement officials or another public or private entity regarding the vehicle’s location. The system provides for the routing delivery of the information to the appropriate law enforcement organization to assist in the recovery of the vehicle.

Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the device meeting

the standards for the higher discount. NOTE: The maximum combinative discount per policy for all discounts listed above is 50%.




III. PHYSICAL DAMAGE RELATIVITY FACTORS

Applies to all policies where the policy contains a single vehicle valued under $10,000. For the value shown, multiply the relativity factor to the appropriate physical damage rate as shown on the Rate Pages.

Vehicle Value Relativity Factor Vehicle Value Relativity Factor

$ 3,000 51.00 $ 6,500 87.75

$ 3,100 52.39 $ 6,600 88.44

$ 3,200 53.76 $ 6,700 89.11

$ 3,300 55.11 $ 6,800 89.76

$ 3,400 56.44 $ 6,900 90.39

$ 3,500 57.75 $ 7,000 91.00

$ 3,600 59.04 $ 7,100 91.59

$ 3,700 60.31 $ 7,200 92.16

$ 3,800 61.56 $ 7,300 92.71

$ 3,900 62.79 $ 7,400 93.24

$ 4,000 64.00 $ 7,500 93.75

$ 4,100 65.19 $ 7,600 94.24

$ 4,200 66.36 $ 7,700 94.71

$ 4,300 67.51 $ 7,800 95.16

$ 4,400 68.64 $ 7,900 95.59

$ 4,500 69.75 $ 8,000 96.00

$ 4,600 70.84 $ 8,100 96.39

$ 4,700 71.91 $ 8,200 96.76

$ 4,800 72.96 $ 8,300 97.11

$ 4,900 73.99 $ 8,400 97.44

$ 5,000 75.00 $ 8,500 97.75

$ 5,100 75.99 $ 8,600 98.04

$ 5,200 76.96 $ 8,700 98.31

$ 5,300 77.91 $ 8,800 98.56

$ 5,400 78.84 $ 8,900 98.79

$ 5,500 79.75 $ 9,000 99.00

$ 5,600 80.64 $ 9,100 99.19

$ 5,700 81.51 $ 9,200 99.36

$ 5,800 82.36 $ 9,300 99.51

$ 5,900 83.19 $ 9,400 99.64

$ 6,000 84.00 $ 9,500 99.75

$ 6,100 84.79 $ 9,600 99.84

$ 6,200 85.56 $ 9,700 99.91

$ 6,300 86.31 $ 9,800 99.96

$ 6,400 87.04 $ 9,900 99.99

$ 10,000 100.00




IV. OPTIONAL ENDORSEMENTS

A. Towing & Labor Emergency Expense Reimbursement Endorsement Massachusetts - AB1106EPC This optional endorsement provides increased Towing and Labor reimbursement coverage, in addition to reimbursement for

other emergency roadside assistance options based on the plan selected. Coverage is provided for all vehicles listed on the policy declarations page.

1. Silver Plan - $9.95 Annual Premium a. $100 Emergency Towing b. $50 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service 2. Gold Plan - $24.95 Annual Premium a. $150 Emergency Towing b. $100 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service e. $250 Emergency Travel Expense f. $2,500 Theft Reward g. $250 Personal Effects h. $100 Ambulance Assistance i. $100 Car Show Expenses 3. Platinum Plan - $34.95 Annual Premium a. $250 Emergency Towing b. $150 Roadside Assistance c. $50 Emergency Lockout d. Lost Key Return Service e. $500 Emergency Travel Expense f. $5,000 Theft Reward g. $500 Personal Effects h. $250 Ambulance Assistance i. $150 Car Show Expenses j. $5,000 Bail Bond k. $1,000 Legal Defense Benefit l. $1,000 Hit and Run Reward m. TrailerGuard $150 each disablement


B. Increased Limits For Spare Parts Coverage Endorsement Massachusetts - AB3861EPC

For an additional premium, the base limit of $500 may be increased.

The increased limit is applicable to all listed vehicles. The additional premium is on a per policy basis.

A rate of $1.00 will be charged for every $100 of coverage.



MASSACHUSETTS

ANTIQUE / CLASSIC VEHICLES 2,500 MILE TIER

BODILY INJURY TO OTHERS LIMIT ONE CAR TWO OR MORE CARS $ 20/40 $ 12 $ 17 $ 50/100 $ 14 $ 19 $100/100 $ 15 $ 21 $100/300 $ 17 $ 24 $300/300 $ 26 $ 38 $250/500 $ 39 $ 58 $300/500 $ 40 $ 60 $500/500 $ 51 $ 76

DAMAGE TO SOMEONE ELSE’S PROPERTY $ 5 $ 7 $ 10 $ 25 $ 8 $ 12 $ 50 $ 10 $ 15 $ 100 $ 14 $ 21 $ 300 $ 24 $ 36 $ 500 $ 35 $ 50

MEDICAL PAYMENTS LIMIT ONE CAR TWO OR MORE CARS $ 5,000 $ 8 $ 14

PERSONAL INJURY PROTECTION ($8,000 Medical Expense - $0 Deductible) ONE CAR TWO OR MORE CARS $ 8 $ 14

UNINSURED MOTORIST COVERAGE LIMIT ONE CAR TWO OR MORE CARS $ 20/40 $ 10 $ 18 $ 50/100 $ 11 $ 20 $100/100 $ 17 $ 31 $100/300 $ 23 $ 42 $300/300 $ 33 $ 60 $250/500 $ 43 $ 78 $300/500 $ 46 $ 83 $500/500 $ 58 $ 105

UNDERINSURED MOTORIST COVERAGE LIMIT ONE CAR TWO OR MORE CARS $ 20/40 $ 9 $ 16 $ 50/100 $ 11 $ 20 $100/100 $ 15 $ 28 $100/300 $ 21 $ 38 $300/300 $ 30 $ 54 $250/500 $ 39 $ 70 $300/500 $ 42 $ 75 $500/500 $ 52 $ 94



MASSACHUSETTS ANTIQUE / CLASSIC VEHICLES

2,500 MILE TIER

PHYSICAL DAMAGE (STATED AMOUNT PER $100) AGE OF CAR

APPLY THESE RATES WHEN $0 SAFETY GLASS DEDUCTIBLE IS SELECTED


DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.32 0.32 0.33 0.36 0.38 0.40 0.75 0.88 0.92

$ 500 0.31 0.31 0.32 0.35 0.37 0.39 0.73 0.85 0.89

$1,000 0.29 0.29 0.30 0.33 0.35 0.37 0.70 0.82 0.86

$2,500 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$5,000 0.27 0.27 0.28 0.31 0.33 0.35 0.65 0.75 0.79

5% 0.26 0.26 0.27 0.30 0.32 0.34 0.63 0.72 0.76

10% 0.24 0.24 0.25 0.28 0.30 0.32 0.59 0.69 0.73

15% 0.22 0.22 0.23 0.26 0.28 0.30 0.55 0.66 0.70

20% 0.20 0.20 0.21 0.24 0.26 0.28 0.50 0.63 0.67



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.31 0.31 0.32 0.35 0.37 0.39 0.72 0.84 0.88

$ 500 0.30 0.30 0.31 0.34 0.36 0.38 0.70 0.81 0.85

$1000 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$2,500 0.27 0.27 0.28 0.31 0.33 0.35 0.64 0.74 0.78

$5.000 0.26 0.26 0.27 0.30 0.32 0.34 0.62 0.71 0.75

5% 0.25 0.25 0.26 0.29 0.31 0.33 0.60 0.68 0.72

10% 0.23 0.23 0.24 0.27 0.29 0.31 0.56 0.65 0.69

15% 0.21 0.21 0.22 0.25 0.27 0.29 0.52 0.62 0.66

20% 0.19 0.19 0.20 0.23 0.25 0.27 0.47 0.59 0.63




2,500 MILE TIER




& COLLISION DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.54 0.54 0.55 0.58 0.60 0.64 1.55 1.78 1.88

$500 0.52 0.52 0.53 0.56 0.58 0.62 1.50 1.71 1.81

$1,000 0.47 0.47 0.48 0.51 0.53 0.57 1.44 1.64 1.74

$2,500 0.45 0.45 0.46 0.49 0.51 0.55 1.37 1.55 1.65

$5,000 0.43 0.43 0.44 0.47 0.49 0.53 1.32 1.48 1.58

5% 0.41 0.41 0.42 0.45 0.47 0.51 1.27 1.41 1.51

10% 0.38 0.38 0.39 0.42 0.44 0.48 1.19 1.34 1.44

15% 0.35 0.35 0.36 0.39 0.41 0.45 1.11 1.26 1.36

20% 0.32 0.32 0.33 0.36 0.38 0.42 1.02 1.18 1.28




Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.53 0.53 0.54 0.57 0.59 0.63 1.51 1.73 1.83

$500 0.51 0.51 0.52 0.55 0.57 0.61 1.46 1.66 1.76

$1,000 0.46 0.46 0.47 0.50 0.52 0.56 1.40 1.59 1.69

$2,500 0.44 0.44 0.45 0.48 0.50 0.54 1.33 1.50 1.60

$5,000 0.42 0.42 0.43 0.46 0.48 0.52 1.28 1.43 1.53

5% 0.40 0.40 0.41 0.44 0.46 0.50 1.23 1.36 1.46

10% 0.37 0.37 0.38 0.41 0.43 0.47 1.15 1.29 1.39

15% 0.34 0.34 0.35 0.38 0.40 0.44 1.07 1.21 1.31

20% 0.31 0.31 0.32 0.35 0.37 0.41 0.98 1.13 1.23




5,000 MILE TIER










5,000 MILE TIER




DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.37 0.37 0.38 0.41 0.43 0.45 0.88 1.05 1.09

$500 0.36 0.36 0.37 0.40 0.42 0.44 0.86 1.02 1.06

$1,000 0.34 0.34 0.35 0.38 0.40 0.42 0.84 0.99 1.03

$2,500 0.32 0.32 0.33 0.36 0.38 0.40 0.81 0.95 0.99

$5,000 0.30 0.30 0.31 0.34 0.36 0.38 0.79 0.92 0.96

5% 0.28 0.28 0.29 0.32 0.34 0.36 0.77 0.89 0.93

10% 0.26 0.26 0.27 0.30 0.32 0.34 0.74 0.85 0.89

15% 0.24 0.24 0.25 0.28 0.30 0.32 0.70 0.81 0.85

20% 0.22 0.22 0.23 0.26 0.28 0.30 0.66 0.77 0.81



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.36 0.36 0.37 0.40 0.42 0.44 0.85 1.01 1.05

$500 0.35 0.35 0.36 0.39 0.41 0.43 0.83 0.98 1.02

$1,000 0.33 0.33 0.34 0.37 0.39 0.41 0.81 0.95 0.99

$2,500 0.31 0.31 0.32 0.35 0.37 0.39 0.78 0.91 0.95

$5,000 0.29 0.29 0.30 0.33 0.35 0.37 0.76 0.88 0.92

5% 0.27 0.27 0.28 0.31 0.33 0.35 0.74 0.85 0.89

10% 0.25 0.25 0.26 0.29 0.31 0.33 0.71 0.81 0.85

15% 0.23 0.23 0.24 0.27 0.29 0.31 0.67 0.77 0.81

20% 0.21 0.21 0.22 0.25 0.27 0.29 0.63 0.73 0.77




5,000 MILE TIER





Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.64 0.64 0.65 0.68 0.70 0.74 1.80 2.07 2.17

$500 0.62 0.62 0.63 0.66 0.68 0.72 1.75 2.01 2.11

$1,000 0.59 0.59 0.60 0.63 0.65 0.69 1.69 1.94 2.04

$2,500 0.56 0.56 0.57 0.60 0.62 0.66 1.61 1.85 1.95

$5,000 0.53 0.53 0.54 0.57 0.59 0.63 1.55 1.78 1.88

5% 0.49 0.49 0.50 0.53 0.55 0.59 1.49 1.71 1.81

10% 0.45 0.45 0.46 0.49 0.51 0.55 1.42 1.63 1.73

15% 0.41 0.41 0.42 0.45 0.47 0.51 1.33 1.54 1.64

20% 0.37 0.37 0.38 0.41 0.43 0.47 1.24 1.45 1.55

APPLY THESE RATES WHEN $100 SAFETY GLASS DEDUCTIBLE IS SELECTED OTHER THAN

COLLISION & COLLISION DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.63 0.63 0.64 0.67 0.69 0.73 1.76 2.02 2.12

$500 0.61 0.61 0.62 0.65 0.67 0.71 1.71 1.96 2.06

$1,000 0.58 0.58 0.59 0.62 0.64 0.68 1.65 1.89 1.99

$2,500 0.55 0.55 0.56 0.59 0.61 0.65 1.57 1.80 1.90

$5,000 0.52 0.52 0.53 0.56 0.58 0.62 1.51 1.73 1.83

5% 0.48 0.48 0.49 0.52 0.54 0.58 1.45 1.66 1.76

10% 0.44 0.44 0.45 0.48 0.50 0.54 1.38 1.58 1.68

15% 0.40 0.40 0.41 0.44 0.46 0.50 1.29 1.49 1.59

20% 0.36 0.36 0.37 0.40 0.42 0.46 1.20 1.40 1.50



MASSACHUSETTS MODIFIED VEHICLES

2,500 MILE TIER










2,500 MILE TIER




Deductible

Vehicles 15+Years with Value >=$40,000

Vehicles 15+Years with Value < $40,000

All Vehicles less than 15 Years

$300 0.70 1.15 1.15

$500 0.67 1.11 1.11

$1,000 0.64 1.07 1.07

$2,500 0.61 1.02 1.02

$5,000 0.59 0.97 0.97

5% 0.57 0.93 0.93

10% 0.50 0.81 0.81

15% 0.43 0.69 0.69

20% 0.36 0.58 0.58



Deductible




$300 0.67 1.12 1.12

$500 0.64 1.08 1.08

$1,000 0.61 1.04 1.04

$2,500 0.58 0.99 0.99

$5,000 0.56 0.94 0.94

5% 0.54 0.90 0.90

10% 0.47 0.78 0.78

15% 0.40 0.66 0.66

20% 0.33 0.55 0.55




2,500 MILE TIER



OTHER THAN COLLISION & COLLISION

Deductible




$300 1.09 1.80 1.80

$500 1.05 1.74 1.74

$1,000 1.01 1.68 1.68

$2,500 0.96 1.61 1.61

$5,000 0.93 1.54 1.54

5% 0.90 1.48 1.48

10% 0.79 1.29 1.29

15% 0.68 1.10 1.10

20% 0.56 0.92 0.92



Deductible




$300 1.06 1.77 1.77

$500 1.02 1.71 1.71

$1,000 0.98 1.65 1.65

$2,500 0.93 1.58 1.58

$5,000 0.90 1.51 1.51

5% 0.87 1.45 1.45

10% 0.76 1.26 1.26

15% 0.65 1.07 1.07

20% 0.53 0.89 0.89



MASSACHUSETTS

MODIFIED VEHICLES 5,000 MILE TIER

BODILY INJURY TO OTHERS

LIMIT ONE CAR TWO OR MORE CARS $ 20/40 $ 54 $ 92 $ 50/100 $ 60 $ 104 $100/100 $ 63 $ 109 $100/300 $ 68 $ 119 $300/300 $ 120 $ 211 $250/500 $ 156 $ 273 $300/500 $ 170 $ 297 $500/500 $ 213 $ 372









5,000 MILE TIER




Deductible




$300 0.81 1.34 1.34

$500 0.78 1.29 1.29

$1,000 0.75 1.24 1.24

$2,500 0.72 1.19 1.19

$5,000 0.69 1.13 1.13

5% 0.66 1.08 1.08

10% 0.58 0.95 0.95

15% 0.50 0.82 0.82

20% 0.42 0.68 0.68



Deductible




$300 0.78 1.31 1.31

$500 0.75 1.26 1.26

$1,000 0.72 1.21 1.21

$2,500 0.69 1.16 1.16

$5,000 0.66 1.10 1.10

5% 0.63 1.05 1.05

10% 0.55 0.92 0.92

15% 0.47 0.79 0.79

20% 0.39 0.65 0.65




5,000 MILE TIER




Deductible




$300 1.26 2.08 2.08

$500 1.22 2.01 2.01

$1,000 1.17 1.94 1.94

$2,500 1.12 1.86 1.86

$5,000 1.07 1.78 1.78

5% 1.03 1.70 1.70

10% 0.90 1.49 1.49

15% 0.77 1.28 1.28

20% 0.64 1.05 1.05



Deductible




$300 1.23 2.05 2.05

$500 1.19 1.98 1.98

$1,000 1.14 1.91 1.91

$2,500 1.09 1.83 1.83

$5,000 1.04 1.75 1.75

5% 1.00 1.67 1.67

10% 0.87 1.46 1.46

15% 0.74 1.25 1.25

20% 0.61 1.02 1.02



MASSACHUSETTS ANTIQUE MOTORCYCLES

2,500 MILE TIER

BODILY INJURY TO OTHERS LIMIT ONE CYCLE TWO OR MORE CYCLES $ 20/40 $ 32 $ 55 $ 50/100 $ 37 $ 63 $100/100 $ 39 $ 66 $100/300 $ 47 $ 80 $300/300 $ 75 $ 130 $250/500 $ 132 $ 228 $300/500 $ 142 $ 244 $500/500 $ 178 $ 306

DAMAGE TO SOMEONE ELSE’S PROPERTY LIMIT ONE CYCLE TWO OR MORE CYCLES $ 5 $ 20 $ 35 $ 25 $ 24 $ 42 $ 50 $ 31 $ 54 $ 100 $ 43 $ 74 $ 300 $ 68 $ 116 $ 500 $ 85 $ 145

PEDESTRIAN PERSONAL INJURY PROTECTION ($8,000 Medical Expense - $0 Deductible) ONE CYCLE TWO OR MORE CYCLES $ 14 $ 24

UNINSURED MOTORIST COVERAGE LIMIT ONE CYCLE TWO OR MORE CYCLES $ 20/40 $ 10 $ 18 $ 50/100 $ 11 $ 20 $100/100 $ 17 $ 31 $100/300 $ 23 $ 42 $300/300 $ 33 $ 60 $250/500 $ 42 $ 77 $300/500 $ 45 $ 82 $500/500 $ 57 $ 103

UNDERINSURED MOTORIST COVERAGE LIMIT ONE CYCLE TWO OR MORE CYCLES $ 20/40 $ 9 $ 16 $ 50/100 $ 11 $ 20 $100/100 $ 16 $ 29 $100/300 $ 21 $ 38 $300/300 $ 30 $ 54 $250/500 $ 39 $ 70 $300/500 $ 41 $ 74 $500/500 $ 51 $ 92




2,500 MILE TIER

PHYSICAL DAMAGE (STATED AMOUNT PER $100) AGE OF CYCLE



Deductible 1895-1950 1951-Sub.

$300 1.15 1.15

$500 1.11 1.11

$1,000 1.07 1.07

$2,500 1.02 1.02

$5,000 0.97 0.97

5% 0.93 0.93

10% 0.81 0.81

15% 0.69 0.69

20% 0.58 0.58




$300 1.12 1.12

$500 1.08 1.08

$1,000 1.04 1.04

$2,500 0.99 0.99

$5,000 0.94 0.94

5% 0.90 0.90

10% 0.78 0.78

15% 0.66 0.66

20% 0.55 0.55




2,500 MILE TIER





$300 1.80 1.80

$500 1.74 1.74

$1,000 1.68 1.68

$2,500 1.61 1.61

$5,000 1.54 1.54

5% 1.48 1.48

10% 1.29 1.29

15% 1.10 1.10

20% 0.92 0.92




$300 1.77 1.77

$500 1.71 1.71

$1,000 1.65 1.65

$2,500 1.58 1.58

$5,000 1.51 1.51

5% 1.45 1.45

10% 1.26 1.26

15% 1.07 1.07

20% 0.89 0.89

ANTIQUE MOTORCYCLES

5,000 MILE TIER

5,000 Mile Tier is not available for Antique Motorcycle.





FORMS

Form Number Description ISO Forms: PP 00 01 01 05 Personal Auto Policy PP 05 75 04 12 Personal Injury Protection Coverage Massachusetts PP 13 01 12 99 Coverage for Damage to Your Auto Exclusion PP 03 10 08 86 Change Endorsement Mandatory Forms: AJ9898JPC Policy Jacket ANA0001D Policy Declarations Page ID0001 Massachusetts Insurance Identification Card PCG-OFAC Economic Sanctions Endorsement Mandatory Endorsements: AB3807EPC Amendment of Policy Provisions Massachusetts AB3808EPC Uninsured Motorists Coverage Massachusetts AB3811EPC Antique Auto Coverage Endorsement Massachusetts AB3814EPC Other Than Collision Coverage Glass Options Massachusetts AB3815EPC Collision Coverage Waiver of Deductible Massachusetts AH9675ERR Vehicle/Coverage Schedule Massachusetts Optional Endorsements: AB1106EPC Towing and Labor Emergency Expense Reimbursement Massachusetts AB3809EPC Underinsured Motorists Coverage Massachusetts AB3810EPC Named Driver Exclusion Endorsement Massachusetts AB3825EPC Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3861EPC Increased Limits for Spare Parts Coverage Endorsement Massachusetts





1. An Antique vehicle means a private passenger vehicle, which is: a. At least twenty five years old; b. Used for exhibitions; club activities, parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected. 2. A Classic vehicle means a private passenger vehicle, which is:

a. Newer than twenty five years old where the vehicle is considered to be appreciating in value and is of unique or rare design or limited production;

b. Used for exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected.

3. A Modified vehicle means a private passenger vehicle which is: a. Modified from its original specifications; b. Used for: exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. Not used for general transportation; and d. Driven no more than 2,500 or 5,000 miles during an annual policy term, dependent upon the mileage tier selected. Replica or kit cars are considered Modified vehicles.

II. ELIGIBILITY


























3. Endorsement: Attach Named Driver Exclusion Endorsement Massachusetts AB3810EPC.




Attach Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3825EPC.





other emergency roadside assistance options based on the plan selected. Coverage is provided for all vehicles listed on the Policy Declarations Page.



Attach Towing and Labor Emergency Expense Reimbursement Endorsement Massachusetts AB1106EPC. Refer to State Rate Pages for Rates.



Attach Increased Limits For Spare Parts Coverage Endorsement Massachusetts AB3861EPC if additional limits are selected. Refer to State Rate Pages for additional premium.













2 hours.
















Antique vehicles equipped with air bags and/or automatic seat belts. Refer to the State Rate Pages for the discount amount. K. Anti-Theft Devices – Discounts apply to Other than Collision coverage only. Vehicles equipped with Anti-Theft Devices as defined below are entitled to a discount. See Rate Pages for discount amount. Definitions: “Passive” describes an anti-theft or system which is activated automatically when the operator turns the ignition key to the off

































Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the device

meeting the standards for the highest discount.







However, Pedestrian Personal Injury Protection will be afforded to pedestrians if struck by an insured motorcycle. Deductibles Personal Injury Protection has a $0 Deductible. Optional deductibles are available for a reduction in PIP premium. See Rate Pages for

discount factors. Our total payment for medical expenses, lost wages and replacement services will not exceed $8,000

Attach Personal Injury Protection Coverage Massachusetts PP 05 75 Uninsured Motorists Coverage This form of auto insurance must be afforded at limits not less than the financial responsibility limits under every auto liability policy




Attach Uninsured Motorists Coverage Massachusetts - AB3808EPC Underinsured Motorists Coverage This form of coverage shall be offered as an option to the insured at limits up to the Split Liability limits of the policy. When




Attach Underinsured Motorists Coverage – Massachusetts -AB3809EPC







$100 0.92 $250 0.85 $500 0.80

$1,000 0.72 $2,000 0.64 $4,000 0.50 $8,000 0.17









Car Club Discount


High Value Discount



















position.
























2. Passive Fuel Cut-off Device. This fuel cut-off device is engaged by turning the ignition key to the off position. The driver must

trip a switch to open the fuel line each time the vehicle is started. This device must meet the following criteria: a. The fuel line must be blocked when the power is off. b. Switch to open fuel line must be well hidden from view, but accessible to the driver from the driver’s seat. In the







Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the device meeting

the standards for the higher discount. NOTE: The maximum combinative discount per policy for all discounts listed above is 50%.







$ 3,000 51.00 $ 6,500 87.75

$ 3,100 52.39 $ 6,600 88.44

$ 3,200 53.76 $ 6,700 89.11

$ 3,300 55.11 $ 6,800 89.76

$ 3,400 56.44 $ 6,900 90.39

$ 3,500 57.75 $ 7,000 91.00

$ 3,600 59.04 $ 7,100 91.59

$ 3,700 60.31 $ 7,200 92.16

$ 3,800 61.56 $ 7,300 92.71

$ 3,900 62.79 $ 7,400 93.24

$ 4,000 64.00 $ 7,500 93.75

$ 4,100 65.19 $ 7,600 94.24

$ 4,200 66.36 $ 7,700 94.71

$ 4,300 67.51 $ 7,800 95.16

$ 4,400 68.64 $ 7,900 95.59

$ 4,500 69.75 $ 8,000 96.00

$ 4,600 70.84 $ 8,100 96.39

$ 4,700 71.91 $ 8,200 96.76

$ 4,800 72.96 $ 8,300 97.11

$ 4,900 73.99 $ 8,400 97.44

$ 5,000 75.00 $ 8,500 97.75

$ 5,100 75.99 $ 8,600 98.04

$ 5,200 76.96 $ 8,700 98.31

$ 5,300 77.91 $ 8,800 98.56

$ 5,400 78.84 $ 8,900 98.79

$ 5,500 79.75 $ 9,000 99.00

$ 5,600 80.64 $ 9,100 99.19

$ 5,700 81.51 $ 9,200 99.36

$ 5,800 82.36 $ 9,300 99.51

$ 5,900 83.19 $ 9,400 99.64

$ 6,000 84.00 $ 9,500 99.75

$ 6,100 84.79 $ 9,600 99.84

$ 6,200 85.56 $ 9,700 99.91

$ 6,300 86.31 $ 9,800 99.96

$ 6,400 87.04 $ 9,900 99.99

$ 10,000 100.00





A. Towing & Labor Emergency Expense Reimbursement Endorsement Massachusetts - AB1106EPC-1014 This optional endorsement provides increased Towing and Labor reimbursement coverage, in addition to reimbursement for




B. Increased Limits For Spare Parts Coverage Endorsement Massachusetts - AB3861EPC






MASSACHUSETTS











2,500 MILE TIER




DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.32 0.32 0.33 0.36 0.38 0.40 0.75 0.88 0.92

$ 500 0.31 0.31 0.32 0.35 0.37 0.39 0.73 0.85 0.89

$1,000 0.29 0.29 0.30 0.33 0.35 0.37 0.70 0.82 0.86

$2,500 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$5,000 0.27 0.27 0.28 0.31 0.33 0.35 0.65 0.75 0.79

5% 0.26 0.26 0.27 0.30 0.32 0.34 0.63 0.72 0.76

10% 0.24 0.24 0.25 0.28 0.30 0.32 0.59 0.69 0.73

15% 0.22 0.22 0.23 0.26 0.28 0.30 0.55 0.66 0.70

20% 0.20 0.20 0.21 0.24 0.26 0.28 0.50 0.63 0.67



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.31 0.31 0.32 0.35 0.37 0.39 0.72 0.84 0.88

$ 500 0.30 0.30 0.31 0.34 0.36 0.38 0.70 0.81 0.85

$1000 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$2,500 0.27 0.27 0.28 0.31 0.33 0.35 0.64 0.74 0.78

$5.000 0.26 0.26 0.27 0.30 0.32 0.34 0.62 0.71 0.75

5% 0.25 0.25 0.26 0.29 0.31 0.33 0.60 0.68 0.72

10% 0.23 0.23 0.24 0.27 0.29 0.31 0.56 0.65 0.69

15% 0.21 0.21 0.22 0.25 0.27 0.29 0.52 0.62 0.66

20% 0.19 0.19 0.20 0.23 0.25 0.27 0.47 0.59 0.63




2,500 MILE TIER





Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.54 0.54 0.55 0.58 0.60 0.64 1.55 1.78 1.88

$500 0.52 0.52 0.53 0.56 0.58 0.62 1.50 1.71 1.81

$1,000 0.47 0.47 0.48 0.51 0.53 0.57 1.44 1.64 1.74

$2,500 0.45 0.45 0.46 0.49 0.51 0.55 1.37 1.55 1.65

$5,000 0.43 0.43 0.44 0.47 0.49 0.53 1.32 1.48 1.58

5% 0.41 0.41 0.42 0.45 0.47 0.51 1.27 1.41 1.51

10% 0.38 0.38 0.39 0.42 0.44 0.48 1.19 1.34 1.44

15% 0.35 0.35 0.36 0.39 0.41 0.45 1.11 1.26 1.36

20% 0.32 0.32 0.33 0.36 0.38 0.42 1.02 1.18 1.28




Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.53 0.53 0.54 0.57 0.59 0.63 1.51 1.73 1.83

$500 0.51 0.51 0.52 0.55 0.57 0.61 1.46 1.66 1.76

$1,000 0.46 0.46 0.47 0.50 0.52 0.56 1.40 1.59 1.69

$2,500 0.44 0.44 0.45 0.48 0.50 0.54 1.33 1.50 1.60

$5,000 0.42 0.42 0.43 0.46 0.48 0.52 1.28 1.43 1.53

5% 0.40 0.40 0.41 0.44 0.46 0.50 1.23 1.36 1.46

10% 0.37 0.37 0.38 0.41 0.43 0.47 1.15 1.29 1.39

15% 0.34 0.34 0.35 0.38 0.40 0.44 1.07 1.21 1.31

20% 0.31 0.31 0.32 0.35 0.37 0.41 0.98 1.13 1.23




5,000 MILE TIER










5,000 MILE TIER




DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.37 0.37 0.38 0.41 0.43 0.45 0.88 1.05 1.09

$500 0.36 0.36 0.37 0.40 0.42 0.44 0.86 1.02 1.06

$1,000 0.34 0.34 0.35 0.38 0.40 0.42 0.84 0.99 1.03

$2,500 0.32 0.32 0.33 0.36 0.38 0.40 0.81 0.95 0.99

$5,000 0.30 0.30 0.31 0.34 0.36 0.38 0.79 0.92 0.96

5% 0.28 0.28 0.29 0.32 0.34 0.36 0.77 0.89 0.93

10% 0.26 0.26 0.27 0.30 0.32 0.34 0.74 0.85 0.89

15% 0.24 0.24 0.25 0.28 0.30 0.32 0.70 0.81 0.85

20% 0.22 0.22 0.23 0.26 0.28 0.30 0.66 0.77 0.81



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.36 0.36 0.37 0.40 0.42 0.44 0.85 1.01 1.05

$500 0.35 0.35 0.36 0.39 0.41 0.43 0.83 0.98 1.02

$1,000 0.33 0.33 0.34 0.37 0.39 0.41 0.81 0.95 0.99

$2,500 0.31 0.31 0.32 0.35 0.37 0.39 0.78 0.91 0.95

$5,000 0.29 0.29 0.30 0.33 0.35 0.37 0.76 0.88 0.92

5% 0.27 0.27 0.28 0.31 0.33 0.35 0.74 0.85 0.89

10% 0.25 0.25 0.26 0.29 0.31 0.33 0.71 0.81 0.85

15% 0.23 0.23 0.24 0.27 0.29 0.31 0.67 0.77 0.81

20% 0.21 0.21 0.22 0.25 0.27 0.29 0.63 0.73 0.77




5,000 MILE TIER





Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.64 0.64 0.65 0.68 0.70 0.74 1.80 2.07 2.17

$500 0.62 0.62 0.63 0.66 0.68 0.72 1.75 2.01 2.11

$1,000 0.59 0.59 0.60 0.63 0.65 0.69 1.69 1.94 2.04

$2,500 0.56 0.56 0.57 0.60 0.62 0.66 1.61 1.85 1.95

$5,000 0.53 0.53 0.54 0.57 0.59 0.63 1.55 1.78 1.88

5% 0.49 0.49 0.50 0.53 0.55 0.59 1.49 1.71 1.81

10% 0.45 0.45 0.46 0.49 0.51 0.55 1.42 1.63 1.73

15% 0.41 0.41 0.42 0.45 0.47 0.51 1.33 1.54 1.64

20% 0.37 0.37 0.38 0.41 0.43 0.47 1.24 1.45 1.55

APPLY THESE RATES WHEN $100 SAFETY GLASS DEDUCTIBLE IS SELECTED OTHER THAN

COLLISION & COLLISION DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.63 0.63 0.64 0.67 0.69 0.73 1.76 2.02 2.12

$500 0.61 0.61 0.62 0.65 0.67 0.71 1.71 1.96 2.06

$1,000 0.58 0.58 0.59 0.62 0.64 0.68 1.65 1.89 1.99

$2,500 0.55 0.55 0.56 0.59 0.61 0.65 1.57 1.80 1.90

$5,000 0.52 0.52 0.53 0.56 0.58 0.62 1.51 1.73 1.83

5% 0.48 0.48 0.49 0.52 0.54 0.58 1.45 1.66 1.76

10% 0.44 0.44 0.45 0.48 0.50 0.54 1.38 1.58 1.68

15% 0.40 0.40 0.41 0.44 0.46 0.50 1.29 1.49 1.59

20% 0.36 0.36 0.37 0.40 0.42 0.46 1.20 1.40 1.50




2,500 MILE TIER










2,500 MILE TIER




Deductible




$300 0.70 1.15 1.15

$500 0.67 1.11 1.11

$1,000 0.64 1.07 1.07

$2,500 0.61 1.02 1.02

$5,000 0.59 0.97 0.97

5% 0.57 0.93 0.93

10% 0.50 0.81 0.81

15% 0.43 0.69 0.69

20% 0.36 0.58 0.58



Deductible




$300 0.67 1.12 1.12

$500 0.64 1.08 1.08

$1,000 0.61 1.04 1.04

$2,500 0.58 0.99 0.99

$5,000 0.56 0.94 0.94

5% 0.54 0.90 0.90

10% 0.47 0.78 0.78

15% 0.40 0.66 0.66

20% 0.33 0.55 0.55




2,500 MILE TIER




Deductible




$300 1.09 1.80 1.80

$500 1.05 1.74 1.74

$1,000 1.01 1.68 1.68

$2,500 0.96 1.61 1.61

$5,000 0.93 1.54 1.54

5% 0.90 1.48 1.48

10% 0.79 1.29 1.29

15% 0.68 1.10 1.10

20% 0.56 0.92 0.92



Deductible




$300 1.06 1.77 1.77

$500 1.02 1.71 1.71

$1,000 0.98 1.65 1.65

$2,500 0.93 1.58 1.58

$5,000 0.90 1.51 1.51

5% 0.87 1.45 1.45

10% 0.76 1.26 1.26

15% 0.65 1.07 1.07

20% 0.53 0.89 0.89



MASSACHUSETTS












5,000 MILE TIER




Deductible




$300 0.81 1.34 1.34

$500 0.78 1.29 1.29

$1,000 0.75 1.24 1.24

$2,500 0.72 1.19 1.19

$5,000 0.69 1.13 1.13

5% 0.66 1.08 1.08

10% 0.58 0.95 0.95

15% 0.50 0.82 0.82

20% 0.42 0.68 0.68



Deductible




$300 0.78 1.31 1.31

$500 0.75 1.26 1.26

$1,000 0.72 1.21 1.21

$2,500 0.69 1.16 1.16

$5,000 0.66 1.10 1.10

5% 0.63 1.05 1.05

10% 0.55 0.92 0.92

15% 0.47 0.79 0.79

20% 0.39 0.65 0.65




5,000 MILE TIER




Deductible




$300 1.26 2.08 2.08

$500 1.22 2.01 2.01

$1,000 1.17 1.94 1.94

$2,500 1.12 1.86 1.86

$5,000 1.07 1.78 1.78

5% 1.03 1.70 1.70

10% 0.90 1.49 1.49

15% 0.77 1.28 1.28

20% 0.64 1.05 1.05



Deductible




$300 1.23 2.05 2.05

$500 1.19 1.98 1.98

$1,000 1.14 1.91 1.91

$2,500 1.09 1.83 1.83

$5,000 1.04 1.75 1.75

5% 1.00 1.67 1.67

10% 0.87 1.46 1.46

15% 0.74 1.25 1.25

20% 0.61 1.02 1.02




2,500 MILE TIER









2,500 MILE TIER





$300 1.15 1.15

$500 1.11 1.11

$1,000 1.07 1.07

$2,500 1.02 1.02

$5,000 0.97 0.97

5% 0.93 0.93

10% 0.81 0.81

15% 0.69 0.69

20% 0.58 0.58




$300 1.12 1.12

$500 1.08 1.08

$1,000 1.04 1.04

$2,500 0.99 0.99

$5,000 0.94 0.94

5% 0.90 0.90

10% 0.78 0.78

15% 0.66 0.66

20% 0.55 0.55




2,500 MILE TIER





$300 1.80 1.80

$500 1.74 1.74

$1,000 1.68 1.68

$2,500 1.61 1.61

$5,000 1.54 1.54

5% 1.48 1.48

10% 1.29 1.29

15% 1.10 1.10

20% 0.92 0.92




$300 1.77 1.77

$500 1.71 1.71

$1,000 1.65 1.65

$2,500 1.58 1.58

$5,000 1.51 1.51

5% 1.45 1.45

10% 1.26 1.26

15% 1.07 1.07

20% 0.89 0.89

ANTIQUE MOTORCYCLES

5,000 MILE TIER



A STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY INCORPORATED UNDER THE LAWS OF ILLINOIS


ANTIQUE & COLLECTIBLE VEHICLE POLICY In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative.



Secretary President

AJ9898JPC-0316 © American International Group, Inc. All rights reserved.Includes copyrighted material of Insurance Services Office, Inc., with its permission.

Page 1 of 1

{ {{ {

ANA0001D-0316 © American International Group, Inc. All rights reserved. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc.,



[A Stock Company]

Policy Declarations Page Producer


Named Insured


Collector Vehicles


Selected Coverages



Vehicle Premium


Alternate Addresses

Excluded Drivers





It is agreed that no coverage is afforded under the policy for the person(s) excluded below or on the policy Declarations. We will not be held liable for any accident, damages, losses, or claims arising out of the operation or use of any vehicle whether or not that operation or use was with the express or implied permission of an “insured” under the policy. This coverage exclusion applies to all coverages including:

• Medical Payments,

• Agreed Value Other than Collision; or

• Agreed Value Other than Collision and Collision.


















Yes No


NAME DATE OF

BIRTH

RELATIONSHIP


YEARS

LICENSED

OPERATES

COLLECTOR

MOTORCYCLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household

Member 3

Yes No Yes No

Household Member 4

Yes No Yes No



COMPANY

PROVIDED

VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD

In the last 3 years, have you or any household driver had any convictions for: moving violations, suspensions, accidents, alcohol/drug related offenses or careless/reckless driving; or any insurance claims: If so, please describe below.

Applicant Yes No

Household

Member 2 Yes No

Household

Member 3 Yes No

Household

Member 4 Yes No

PRODUCER # ____________________

QUOTE #________________________

496 Kings Highway North • P.O. Box 8343 • Cherry Hill, NJ 08002-0343 Telephone: 800-360-2277 • Fax 856-779-7289 Underwritten By New Hampshire Insurance Company






Veh. 1

Veh. 2

Veh. 3





Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS MOTORCYCLE

MODIFIED OR

CUSTOMIZED?







Hobby Related

Activities


club events)

Visiting Friends or


Occasional General

Transportation


trips to work)

Timed or Racing

Events OTHER*

ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES














based emergency Roadside assistance plan specific for Collectors. If you would like to learn more about this affordable plan call us at (800) 360-2277.









G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience and Vehicles with anti-theft devices. Please contact New Hampshire Insurance Company for additional details.



CONSUMER REPORTS

A consumer report about you or other individuals listed as policyholders, drivers or household members (e.g. driving record, claims history) may be

requested in connection with this application, policy amendments and/or renewals. This consumer report information which we have or may obtain will be

treated confidentially and will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law. OTHER NON-PUBLIC PERSONAL INFORMATION

Information contained in this application and any additional non-public personal information subsequently collected, will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law.

YOUR RIGHTS

You have the right to see personal information collected about you, and you have the right to correct any information which may be wrong. You may

obtain a more detailed description of our information practices and your rights regarding information we collect by viewing our privacy policy online at

www.NewHampshireInsuranceCompany.com, calling New Hampshire Insurance Company, or, if you have been issued a policy, you may write us at the address provided with your policy.

FRAUD WARNING

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals, for the purpose of

misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and

subjects such person to criminal and civil penalties,.


Limitations of Use-Insured motorcycle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type

transportation. Collector motorcycles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These

motorcycles may not be used for any timed or racing events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder

or declarations page). Motorcycle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been approved by New Hampshire Insurance Company (subject to state availability).

Acknowledgements

1. The information provided to complete the application was provided by me and, to the best of my knowledge, is accurate and true.

2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire Insurance Company.

3. The collector motorcycle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will remain as such. Furthermore, I will advise New Hampshire Insurance Company of any changes in the named insured.

4. I acknowledge that the collector motorcycle(s) does not currently have any unrepaired damage and further understand that New Hampshire

Insurance Company is not responsible for any damage that was sustained to the insured motorcycle(s) prior to the issuance of this policy. 5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy)

may operate any motorcycle insured by New Hampshire Insurance Company.

6. Our policies are subject to a non-refundable, minimum earned premium of $50.00. 7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector motorcycle within 20 days.

Any photograph will become property of New Hampshire Insurance Company and will not be returned.


I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I

agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING THIS APPLICATION AND ANY SUBSEQUENT SERVICE NEEDS? Phone or Email












Yes No


NAME DATE OF

BIRTH

RELATIONSHIP


YEARS

LICENSED

OPERATES

COLLECTOR

VEHICLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household

Member 2

Yes No Yes No

Household Member 3

Yes No Yes No

Household

Member 4

Yes No Yes No



IS THIS A

COMPANY

VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD



Applicant Yes No

Household Member 2

Yes No

Household Member 3

Yes No

Household Member 4

Yes No

PRODUCER # ____________________

QUOTE #________________________







Veh. 1

Veh. 2

Veh. 3





Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS VEHICLE

MODIFIED OR

CUSTOMIZED?







Hobby Related

Activities


club events)

Visiting

Friends or

Family

Exercising

the motor

Occasional General

Transportation


trips to work)

Timed or Racing

Events


OTHER* ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES




[ $20,000/40,000/5,000] [ $50,000/100,000/25,000] [ $100,000/300,000/50,000]



[ $8,000]





















G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience. Vehicles with anti-theft devices or passive restraint devices. Please contact New Hampshire Insurance Company for additional details.



CONSUMER REPORTS





YOUR RIGHTS




FRAUD WARNING






Limitations of Use-Insured vehicle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type

transportation. Only under the Freedom Tier option with a mileage limitation of 7,500 is occasional general use acceptable (subject to state availability).

Collector vehicles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These vehicles may not be

used for any timed, racing or Driver’s Education events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder or declarations page). Vehicle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been

approved by New Hampshire Insurance Company (subject to state availability). Acknowledgements


2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire Insurance Company. 3. The collector vehicle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will

remain as such. Furthermore, I will advise New Hampshire Insurance Company of any changes in the named insured.

4. I acknowledge that the collector vehicle(s) does not currently have any unrepaired damage and further understand that New Hampshire Insurance Company is not responsible for any damage that was sustained to the insured vehicle(s) prior to the issuance of this policy.

5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy)

may operate any vehicle insured by New Hampshire Insurance Company. 6. Our policies are subject to a non-refundable, minimum earned premium of $50.00.

7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector vehicle within 20 days.



I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued,

whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING THIS APPLICATION AND ANY SUBSEQUENT SERVICE NEEDS?

Phone or Email
















a. Is considered to be appreciating in value, and is either;


















This Exclusion (A.7) does not apply to the

maintenance or use of a: a. Your “covered auto”; or b. “Trailer” used with “your covered auto”.








AUTO INSURING AGREEMENT, item A is deleted and











INSURING AGREEMENT, item C is deleted in its

entirety.

TRANSPORTATION EXPENSES is deleted in its entirety.

The following coverage is added: SPARE PARTS COVERAGE


We do not cover:


and control.






















14. Loss to any covered auto being maintained, used, or held by any person or dealer for consignment or sale.




LIMIT OF LIABILITY The following are added to Sections A. and B. : AGREED VALUE COVERAGE In the event of loss to “your covered auto” we will, subject







currently on the policy; or 3. $100,000; or 4. The purchase price, whichever is less. Such additional or replacement vehicles must be


PAYMENT OF LOSS, The last sentence, is deleted

and replaced with the following: If we pay for loss in money, our payment will include the

applicable sales tax for the damaged or stolen property subject to the maximum limit of liability shown in the Declarations.





VEHICLE TRAILER






Administrative Office: American Collectors Insurance, Inc.

P.O. Box 8343, Cherry Hill, NJ 08002 (800) 360-2277

A STOCK INSURANCE COMPANY HEREIN CALLED THE COMPANY

INCORPORATED UNDER THE LAWS OF ILLINOIS





Secretary President


Page 1 of 1

{ {{ {






Bodily Injury Liability,

Property Damage Liability,

Medical Payments,

Personal Injury Protection,

Uninsured / Underinsured Motorist,

Agreed Value Other than Collision; or

Agreed Value Other than Collision and Collision.










[A Stock Company] Send all correspondence to American Collectors Insurance, Inc.

Box 8343, Cherry Hill NJ 08002 800.360.2277



Named Insured


Collector Vehicles


Selected Coverages



Vehicle Premium


Alternate Addresses

Excluded Drivers




















entirety.

TRANSPORTATION EXPENSES is deleted in its entirety.

The following coverage is added: SPARE PARTS COVERAGE


We do not cover:


and control.






















14. Loss to any covered auto being maintained, used, or held by any person or dealer for consignment or sale.




LIMIT OF LIABILITY The following are added to Sections A. and B. : AGREED VALUE COVERAGE In the event of loss to “your covered auto” we will, subject









PAYMENT OF LOSS, The last sentence, is deleted

and replaced with the following: If we pay for loss in money, our payment will include the

applicable sales tax for the damaged or stolen property subject to the maximum limit of liability shown in the Declarations.





VEHICLE TRAILER
















Yes No


NAME DATE OF

BIRTH

RELATIONSHIP


YEARS

LICENSED

OPERATES

COLLECTOR

MOTORCYCLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household

Member 3

Yes No Yes No

Household Member 4

Yes No Yes No



COMPANY

PROVIDED

VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD


Applicant Yes No

Household

Member 2 Yes No

Household

Member 3 Yes No

Household

Member 4 Yes No

PRODUCER # ____________________

QUOTE #________________________







Veh. 1

Veh. 2

Veh. 3





Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS MOTORCYCLE

MODIFIED OR

CUSTOMIZED?







Hobby Related

Activities


club events)

Visiting Friends or


Occasional General

Transportation


trips to work)

Timed or Racing

Events OTHER*

ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES














based emergency Roadside assistance plan specific for Collectors. If you would like to learn more about this affordable plan call us at (800) 360-2277.









G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience and Vehicles with anti-theft devices. Please contact New Hampshire Insurance Company for additional details.



CONSUMER REPORTS





YOUR RIGHTS




FRAUD WARNING






Limitations of Use-Insured motorcycle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type

transportation. Collector motorcycles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These

motorcycles may not be used for any timed or racing events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder

or declarations page). Motorcycle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been approved by New Hampshire Insurance Company (subject to state availability).

Acknowledgements


2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire Insurance Company.

3. The collector motorcycle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will remain as such. Furthermore, I will advise New Hampshire Insurance Company of any changes in the named insured.

4. I acknowledge that the collector motorcycle(s) does not currently have any unrepaired damage and further understand that New Hampshire


may operate any motorcycle insured by New Hampshire Insurance Company.

6. Our policies are subject to a non-refundable, minimum earned premium of $50.00. 7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector motorcycle within 20 days.



I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I

agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE













Yes No


NAME DATE OF

BIRTH

RELATIONSHIP


YEARS

LICENSED

OPERATES

COLLECTOR

VEHICLE

EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household

Member 2

Yes No Yes No

Household Member 3

Yes No Yes No

Household

Member 4

Yes No Yes No



IS THIS A

COMPANY

VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD



Applicant Yes No

Household Member 2

Yes No

Household Member 3

Yes No

Household Member 4

Yes No

PRODUCER # ____________________

QUOTE #________________________







Veh. 1

Veh. 2

Veh. 3





Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS VEHICLE

MODIFIED OR

CUSTOMIZED?







Hobby Related

Activities


club events)

Visiting

Friends or

Family

Exercising

the motor

Occasional General

Transportation


trips to work)

Timed or Racing

Events


OTHER* ANNUAL

MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES




[ $20,000/40,000/5,000] [ $50,000/100,000/25,000] [ $100,000/300,000/50,000]



[ $8,000]





















G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience. Vehicles with anti-theft devices or passive restraint devices. Please contact New Hampshire Insurance Company for additional details.



CONSUMER REPORTS





YOUR RIGHTS




FRAUD WARNING






Limitations of Use-Insured vehicle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type

transportation. Only under the Freedom Tier option with a mileage limitation of 7,500 is occasional general use acceptable (subject to state availability).

Collector vehicles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These vehicles may not be

used for any timed, racing or Driver’s Education events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder or declarations page). Vehicle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been

approved by New Hampshire Insurance Company (subject to state availability). Acknowledgements


2. I have reviewed the attached offer of insurance and accept the coverage limits offered by New Hampshire Insurance Company. 3. The collector vehicle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will

remain as such. Furthermore, I will advise New Hampshire Insurance Company of any changes in the named insured.

4. I acknowledge that the collector vehicle(s) does not currently have any unrepaired damage and further understand that New Hampshire Insurance Company is not responsible for any damage that was sustained to the insured vehicle(s) prior to the issuance of this policy.

5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy)

may operate any vehicle insured by New Hampshire Insurance Company. 6. Our policies are subject to a non-refundable, minimum earned premium of $50.00.

7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector vehicle within 20 days.



I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued,

whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE

HOW WOULD YOU LIKE TO BE CONTACTED REGARDING THIS APPLICATION AND ANY SUBSEQUENT SERVICE NEEDS?

Phone or Email


(STATE)






INSURED

ID0001-0316



Page 1 of 2





each vehicle involved.4. Report the accident to New Hampshire Insurance Company at your



(800) 360-2277



Page 2 of 2

AH9675ERR-0316 © American International Group, Inc. All rights reserved. Page 1 of 1



MASSACHUSETTS

NO.

YEAR

TRADE NAME

BODY TYPE

MODEL

IDENTIFICATION NO.

COVERAGE AMOUNT


COLLISION

PART

COVERAGES - LIMITS

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM

AUTO PREMIUM








Medical Payments,




Agreed Value Other than Collision and Collision.










MASSACHUSETTS










[ $20,000/$40,000] [ $50,000/$100,000] [ $100,000/$100,000] [ $100,000/$300,000] [ $300,000/$300,000] [ $250,000/$500,000] [ $300,000/$500,000] [ $500,000/$500,000]

Reject Underinsured Motorist coverage entirely I have read and understand the contents of this notice regarding Uninsured/Underinsured Motorists Coverage. I understand and agree that this coverage election applies to my Antique Automobile Policy and future renewals until I advise the Company or its authorized representative, in writing, to the contrary.


X DATE

/ /








Named Insured


Collector Vehicles


Selected Coverages



Vehicle Premium


Alternate Addresses

Excluded Drivers










Secretary President


Page 1 of 1

{ {{ {


(STATE)






INSURED

ID0001-0316



Page 1 of 2





each vehicle involved.4. Report the accident to American Collectors Insurance LLC at your



(800) 360-2277



Page 2 of 2





FORMS

Form Number Description ISO Forms: PP 00 01 01 05 Personal Auto Policy PP 05 75 04 12 Personal Injury Protection Coverage Massachusetts PP 13 01 12 99 Coverage for Damage to Your Auto Exclusion Mandatory Forms: AJ9898JPC Policy Jacket ANA0001D Policy Declaration Page ID0001 Massachusetts Insurance Identification Card Mandatory Endorsements: AB3807EPC Amendment of Policy Provisions Endorsement Massachusetts AB3808EPC Uninsured Motorists Coverage Massachusetts AB3811EPC Antique Auto Coverage Endorsement Massachusetts AB3814EPC Other Than Collision Coverage Glass Options Massachusetts AB3815EPC Collision Coverage Waiver of Deductible Massachusetts AH9675ERR Vehicle/Coverage Schedule Massachusetts Optional Endorsements: AB1106EPC Towing and Labor Emergency Expense Reimbursement Massachusetts AB3809EPC Underinsured Motorists Coverage Massachusetts AB3810EPC Named Driver Exclusion Endorsement Massachusetts AB3825EPC Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3861EPC Increased Limits for Spare Parts Coverage Endorsement Massachusetts





1. An Antique vehicle means a private passenger vehicle, which is: a. at least twenty five years old; b. used for exhibitions; club activities, parades; or other functions of public interest; occasional pleasure drives; c. not used for general transportation; and d. driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected. 2. A Classic vehicle means a private passenger vehicle, which is:

a. newer than twenty five years old where the vehicle is considered to be appreciating in value and is of unique or rare design or limited production;

b. used for exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. not used for general transportation; and d. driven no more than 2,500 or 5,000 during an annual policy term, dependent upon the mileage tier selected.

3. A Modified vehicle means a private passenger vehicle which is: a. modified from its original specifications; b. used for: exhibitions; club activities; parades; or other functions of public interest; occasional pleasure drives; c. not used for general transportation; and d. driven no more than 2,500 or 5,000 miles during an annual policy term, dependent upon the mileage tier selected. Replica or kit cars are considered Modified vehicles.

II. ELIGIBILITY


























3. Endorsement: Attach Named Driver Exclusion Endorsement Massachusetts AB3810EPC-1014.




Attach Amendatory Endorsement for Antique Motorcycle Coverage Massachusetts AB3825EPC-1014.





other emergency roadside assistance options based on the plan selected. Coverage is provided for all vehicles listed on the Policy Declaration Page.



Attach Towing and Labor Emergency Expense Reimbursement Endorsement Massachusetts AB1106EPC-1014. Refer to State Rate Pages for Rates.



Attach Increased Limits For Spare Parts Coverage Endorsement Massachusetts AB3861EPC-1014 if additional limits are selected. Refer to State Rate Pages for additional premium.













2 hours.
















Antique vehicles equipped with air bags and/or automatic seat belts. Refer to the State Rate Pages for the discount amount. K. Anti-Theft Devices – Discounts apply to Other than Collision coverage only. Vehicles equipped with Anti-Theft Devices as defined below are entitled to a discount. See Rate Pages for discount

amount. Definitions: “Passive” describes an anti-theft or system which is activated automatically when the operator turns the ignition key to the off

































Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the

device meeting the standards for the highest discount.







However, Pedestrian Personal Injury Protection will be afforded to pedestrians if struck by an insured motorcycle. Deductibles Personal Injury Protection has a $0 Deductible. Optional deductibles are available for a reduction in PIP premium. See Rate Pages

for discount factors. Our total payment for medical expenses, lost wages and replacement services will not exceed $8,000

Attach Personal Injury Protection Coverage Massachusetts PP 05 75 04 12 Uninsured Motorists Coverage This form of auto insurance must be afforded at limits not less than the financial responsibility limits under every auto liability policy




Attach Uninsured Motorists Coverage Massachusetts - AB3808EPC-1014 Underinsured Motorists Coverage This form of coverage shall be offered as an option to the insured at limits up to the Split Liability limits of the policy. When




Attach Underinsured Motorists Coverage – Massachusetts -AB3809EPC-1014







$100 0.92 $250 0.85 $500 0.80

$1,000 0.72 $2,000 0.64 $4,000 0.50 $8,000 0.17









Car Club Discount


High Value Discount



















position.
























2. Passive Fuel Cut-off Device. This fuel cut-off device is engaged by turning the ignition key to the off position. The driver








Note: If two or more qualifying devices are attached to a vehicle, the total discount shall be that applicable to the

device meeting the standards for the higher discount. NOTE: The maximum combinative discount per policy for all discounts listed above is 50%.







$ 3,000 51.00 $ 6,500 87.75

$ 3,100 52.39 $ 6,600 88.44

$ 3,200 53.76 $ 6,700 89.11

$ 3,300 55.11 $ 6,800 89.76

$ 3,400 56.44 $ 6,900 90.39

$ 3,500 57.75 $ 7,000 91.00

$ 3,600 59.04 $ 7,100 91.59

$ 3,700 60.31 $ 7,200 92.16

$ 3,800 61.56 $ 7,300 92.71

$ 3,900 62.79 $ 7,400 93.24

$ 4,000 64.00 $ 7,500 93.75

$ 4,100 65.19 $ 7,600 94.24

$ 4,200 66.36 $ 7,700 94.71

$ 4,300 67.51 $ 7,800 95.16

$ 4,400 68.64 $ 7,900 95.59

$ 4,500 69.75 $ 8,000 96.00

$ 4,600 70.84 $ 8,100 96.39

$ 4,700 71.91 $ 8,200 96.76

$ 4,800 72.96 $ 8,300 97.11

$ 4,900 73.99 $ 8,400 97.44

$ 5,000 75.00 $ 8,500 97.75

$ 5,100 75.99 $ 8,600 98.04

$ 5,200 76.96 $ 8,700 98.31

$ 5,300 77.91 $ 8,800 98.56

$ 5,400 78.84 $ 8,900 98.79

$ 5,500 79.75 $ 9,000 99.00

$ 5,600 80.64 $ 9,100 99.19

$ 5,700 81.51 $ 9,200 99.36

$ 5,800 82.36 $ 9,300 99.51

$ 5,900 83.19 $ 9,400 99.64

$ 6,000 84.00 $ 9,500 99.75

$ 6,100 84.79 $ 9,600 99.84

$ 6,200 85.56 $ 9,700 99.91

$ 6,300 86.31 $ 9,800 99.96

$ 6,400 87.04 $ 9,900 99.99

$ 10,000 100.00





A. Towing & Labor Emergency Expense Reimbursement Endorsement Massachusetts - AB1106EPC-1014 This optional endorsement provides increased Towing and Labor reimbursement coverage, in addition to reimbursement for




B. Increased Limits For Spare Parts Coverage Endorsement Massachusetts - AB3861EPC-1014






MASSACHUSETTS











2,500 MILE TIER




DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.32 0.32 0.33 0.36 0.38 0.40 0.75 0.88 0.92

$ 500 0.31 0.31 0.32 0.35 0.37 0.39 0.73 0.85 0.89

$1,000 0.29 0.29 0.30 0.33 0.35 0.37 0.70 0.82 0.86

$2,500 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$5,000 0.27 0.27 0.28 0.31 0.33 0.35 0.65 0.75 0.79

5% 0.26 0.26 0.27 0.30 0.32 0.34 0.63 0.72 0.76

10% 0.24 0.24 0.25 0.28 0.30 0.32 0.59 0.69 0.73

15% 0.22 0.22 0.23 0.26 0.28 0.30 0.55 0.66 0.70

20% 0.20 0.20 0.21 0.24 0.26 0.28 0.50 0.63 0.67



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.31 0.31 0.32 0.35 0.37 0.39 0.72 0.84 0.88

$ 500 0.30 0.30 0.31 0.34 0.36 0.38 0.70 0.81 0.85

$1000 0.28 0.28 0.29 0.32 0.34 0.36 0.67 0.78 0.82

$2,500 0.27 0.27 0.28 0.31 0.33 0.35 0.64 0.74 0.78

$5.000 0.26 0.26 0.27 0.30 0.32 0.34 0.62 0.71 0.75

5% 0.25 0.25 0.26 0.29 0.31 0.33 0.60 0.68 0.72

10% 0.23 0.23 0.24 0.27 0.29 0.31 0.56 0.65 0.69

15% 0.21 0.21 0.22 0.25 0.27 0.29 0.52 0.62 0.66

20% 0.19 0.19 0.20 0.23 0.25 0.27 0.47 0.59 0.63




2,500 MILE TIER





Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.54 0.54 0.55 0.58 0.60 0.64 1.55 1.78 1.88

$500 0.52 0.52 0.53 0.56 0.58 0.62 1.50 1.71 1.81

$1,000 0.47 0.47 0.48 0.51 0.53 0.57 1.44 1.64 1.74

$2,500 0.45 0.45 0.46 0.49 0.51 0.55 1.37 1.55 1.65

$5,000 0.43 0.43 0.44 0.47 0.49 0.53 1.32 1.48 1.58

5% 0.41 0.41 0.42 0.45 0.47 0.51 1.27 1.41 1.51

10% 0.38 0.38 0.39 0.42 0.44 0.48 1.19 1.34 1.44

15% 0.35 0.35 0.36 0.39 0.41 0.45 1.11 1.26 1.36

20% 0.32 0.32 0.33 0.36 0.38 0.42 1.02 1.18 1.28




Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.53 0.53 0.54 0.57 0.59 0.63 1.51 1.73 1.83

$500 0.51 0.51 0.52 0.55 0.57 0.61 1.46 1.66 1.76

$1,000 0.46 0.46 0.47 0.50 0.52 0.56 1.40 1.59 1.69

$2,500 0.44 0.44 0.45 0.48 0.50 0.54 1.33 1.50 1.60

$5,000 0.42 0.42 0.43 0.46 0.48 0.52 1.28 1.43 1.53

5% 0.40 0.40 0.41 0.44 0.46 0.50 1.23 1.36 1.46

10% 0.37 0.37 0.38 0.41 0.43 0.47 1.15 1.29 1.39

15% 0.34 0.34 0.35 0.38 0.40 0.44 1.07 1.21 1.31

20% 0.31 0.31 0.32 0.35 0.37 0.41 0.98 1.13 1.23




5,000 MILE TIER










5,000 MILE TIER




DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.37 0.37 0.38 0.41 0.43 0.45 0.88 1.05 1.09

$500 0.36 0.36 0.37 0.40 0.42 0.44 0.86 1.02 1.06

$1,000 0.34 0.34 0.35 0.38 0.40 0.42 0.84 0.99 1.03

$2,500 0.32 0.32 0.33 0.36 0.38 0.40 0.81 0.95 0.99

$5,000 0.30 0.30 0.31 0.34 0.36 0.38 0.79 0.92 0.96

5% 0.28 0.28 0.29 0.32 0.34 0.36 0.77 0.89 0.93

10% 0.26 0.26 0.27 0.30 0.32 0.34 0.74 0.85 0.89

15% 0.24 0.24 0.25 0.28 0.30 0.32 0.70 0.81 0.85

20% 0.22 0.22 0.23 0.26 0.28 0.30 0.66 0.77 0.81



DEDUCTIBLE

Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.36 0.36 0.37 0.40 0.42 0.44 0.85 1.01 1.05

$500 0.35 0.35 0.36 0.39 0.41 0.43 0.83 0.98 1.02

$1,000 0.33 0.33 0.34 0.37 0.39 0.41 0.81 0.95 0.99

$2,500 0.31 0.31 0.32 0.35 0.37 0.39 0.78 0.91 0.95

$5,000 0.29 0.29 0.30 0.33 0.35 0.37 0.76 0.88 0.92

5% 0.27 0.27 0.28 0.31 0.33 0.35 0.74 0.85 0.89

10% 0.25 0.25 0.26 0.29 0.31 0.33 0.71 0.81 0.85

15% 0.23 0.23 0.24 0.27 0.29 0.31 0.67 0.77 0.81

20% 0.21 0.21 0.22 0.25 0.27 0.29 0.63 0.73 0.77




5,000 MILE TIER





Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.64 0.64 0.65 0.68 0.70 0.74 1.80 2.07 2.17

$500 0.62 0.62 0.63 0.66 0.68 0.72 1.75 2.01 2.11

$1,000 0.59 0.59 0.60 0.63 0.65 0.69 1.69 1.94 2.04

$2,500 0.56 0.56 0.57 0.60 0.62 0.66 1.61 1.85 1.95

$5,000 0.53 0.53 0.54 0.57 0.59 0.63 1.55 1.78 1.88

5% 0.49 0.49 0.50 0.53 0.55 0.59 1.49 1.71 1.81

10% 0.45 0.45 0.46 0.49 0.51 0.55 1.42 1.63 1.73

15% 0.41 0.41 0.42 0.45 0.47 0.51 1.33 1.54 1.64

20% 0.37 0.37 0.38 0.41 0.43 0.47 1.24 1.45 1.55




Model Year

Prior to 1945

Model Year

1945 thru 1959

Model Year

1960 thru 1969

Model Year

1970 thru 1973

Model Year

1974 thru 1978

Model Year

1979 thru 1987

Model Year

1988 thru 1992

Model Year

1993 thru 1997

Model Year

1998 and Newer

$300 0.63 0.63 0.64 0.67 0.69 0.73 1.76 2.02 2.12

$500 0.61 0.61 0.62 0.65 0.67 0.71 1.71 1.96 2.06

$1,000 0.58 0.58 0.59 0.62 0.64 0.68 1.65 1.89 1.99

$2,500 0.55 0.55 0.56 0.59 0.61 0.65 1.57 1.80 1.90

$5,000 0.52 0.52 0.53 0.56 0.58 0.62 1.51 1.73 1.83

5% 0.48 0.48 0.49 0.52 0.54 0.58 1.45 1.66 1.76

10% 0.44 0.44 0.45 0.48 0.50 0.54 1.38 1.58 1.68

15% 0.40 0.40 0.41 0.44 0.46 0.50 1.29 1.49 1.59

20% 0.36 0.36 0.37 0.40 0.42 0.46 1.20 1.40 1.50




2,500 MILE TIER










2,500 MILE TIER




Deductible




$300 0.70 1.15 1.15

$500 0.67 1.11 1.11

$1,000 0.64 1.07 1.07

$2,500 0.61 1.02 1.02

$5,000 0.59 0.97 0.97

5% 0.57 0.93 0.93

10% 0.50 0.81 0.81

15% 0.43 0.69 0.69

20% 0.36 0.58 0.58



Deductible




$300 0.67 1.12 1.12

$500 0.64 1.08 1.08

$1,000 0.61 1.04 1.04

$2,500 0.58 0.99 0.99

$5,000 0.56 0.94 0.94

5% 0.54 0.90 0.90

10% 0.47 0.78 0.78

15% 0.40 0.66 0.66

20% 0.33 0.55 0.55




2,500 MILE TIER




Deductible




$300 1.09 1.80 1.80

$500 1.05 1.74 1.74

$1,000 1.01 1.68 1.68

$2,500 0.96 1.61 1.61

$5,000 0.93 1.54 1.54

5% 0.90 1.48 1.48

10% 0.79 1.29 1.29

15% 0.68 1.10 1.10

20% 0.56 0.92 0.92



Deductible




$300 1.06 1.77 1.77

$500 1.02 1.71 1.71

$1,000 0.98 1.65 1.65

$2,500 0.93 1.58 1.58

$5,000 0.90 1.51 1.51

5% 0.87 1.45 1.45

10% 0.76 1.26 1.26

15% 0.65 1.07 1.07

20% 0.53 0.89 0.89



MASSACHUSETTS












5,000 MILE TIER




Deductible




$300 0.81 1.34 1.34

$500 0.78 1.29 1.29

$1,000 0.75 1.24 1.24

$2,500 0.72 1.19 1.19

$5,000 0.69 1.13 1.13

5% 0.66 1.08 1.08

10% 0.58 0.95 0.95

15% 0.50 0.82 0.82

20% 0.42 0.68 0.68



Deductible




$300 0.78 1.31 1.31

$500 0.75 1.26 1.26

$1,000 0.72 1.21 1.21

$2,500 0.69 1.16 1.16

$5,000 0.66 1.10 1.10

5% 0.63 1.05 1.05

10% 0.55 0.92 0.92

15% 0.47 0.79 0.79

20% 0.39 0.65 0.65




5,000 MILE TIER




Deductible




$300 1.26 2.08 2.08

$500 1.22 2.01 2.01

$1,000 1.17 1.94 1.94

$2,500 1.12 1.86 1.86

$5,000 1.07 1.78 1.78

5% 1.03 1.70 1.70

10% 0.90 1.49 1.49

15% 0.77 1.28 1.28

20% 0.64 1.05 1.05



Deductible




$300 1.23 2.05 2.05

$500 1.19 1.98 1.98

$1,000 1.14 1.91 1.91

$2,500 1.09 1.83 1.83

$5,000 1.04 1.75 1.75

5% 1.00 1.67 1.67

10% 0.87 1.46 1.46

15% 0.74 1.25 1.25

20% 0.61 1.02 1.02




2,500 MILE TIER









2,500 MILE TIER





$300 1.15 1.15

$500 1.11 1.11

$1,000 1.07 1.07

$2,500 1.02 1.02

$5,000 0.97 0.97

5% 0.93 0.93

10% 0.81 0.81

15% 0.69 0.69

20% 0.58 0.58


OTHER THAN COLLISION Deductible 1895-1950 1951-Sub.

$300 1.12 1.12

$500 1.08 1.08

$1,000 1.04 1.04

$2,500 0.99 0.99

$5,000 0.94 0.94

5% 0.90 0.90

10% 0.78 0.78

15% 0.66 0.66

20% 0.55 0.55




2,500 MILE TIER





$300 1.80 1.80

$500 1.74 1.74

$1,000 1.68 1.68

$2,500 1.61 1.61

$5,000 1.54 1.54

5% 1.48 1.48

10% 1.29 1.29

15% 1.10 1.10

20% 0.92 0.92

APPLY THESE RATES WHEN $100 SAFETY GLASS DEDUCTIBLE IS SELECTED OTHER THAN COLLISION & COLLISION


$300 1.77 1.77

$500 1.71 1.71

$1,000 1.65 1.65

$2,500 1.58 1.58

$5,000 1.51 1.51

5% 1.45 1.45

10% 1.26 1.26

15% 1.07 1.07

20% 0.89 0.89

ANTIQUE MOTORCYCLES

5,000 MILE TIER













Yes No


NAME DATE OF

BIRTH RELATIONSHIP TO APPLICANT

DRIVERS LICENSE NUMBER & STATE YEARS

LICENSED

OPERATES COLLECTOR

MOTORCYCLE EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household Member 3

Yes No Yes No

Household Member 4

Yes No Yes No

REGULAR USE VEHICLES (YEAR / MAKE / MODEL)

COMPANY PROVIDED VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD


Applicant Yes No

Household Member 2

Yes No

Household Member 3

Yes No

Household Member 4

Yes No

PRODUCER # ____________________ QUOTE #________________________







Veh. 1

Veh. 2

Veh. 3

STORAGE TYPE* STORAGE LOCATION: If different than mailing or garaging address above. Please include County.

Is the Collector Motorcycle currently In your possession?

LIST LIENHOLDER / FINANCED OR LEASED

Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS MOTORCYCLE MODIFIED OR CUSTOMIZED?







Hobby Related

Activities (I.e. Car shows & car

club events)

Visiting Friends or Family

Exercising the motor

Occasional General Transportation

(I.e. Running errands & trips to work)

Timed or Racing Events

OTHER* ANNUAL MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES

Please note that the liability coverage purchased from us cannot exceed the limits of your regular use vehicles. PLEASE SELECT THE LIMIT OF COVERAGE DESIRED BELOW. All policies must include Other Than Collision Coverage.


[ $20,000/40,000/5,000] DECLINE COVERAGE

PEDESTRIAN PERSONAL INJURY PROTECTION – Medical Expense

[ $8,000]


Please refer to the Massachusetts Uninsured/Underinsured Motorist Selection Form (A1028APC) for available coverage limits. Please complete, sign and attach the form to this application.




TOWING & LABOR FOR COLLECTORS (TLC) PLAN - TLC is a reimbursement based emergency Roadside assistance plan specific for Collectors. If you would

like to learn more about this affordable plan call us at (800) 360-2277. SILVER PLAN ($9.95) DECLINE COVERAGE

INCREASED SPARE PARTS COVERAGE Coverage for additional spare parts that belong on the collector vehicle.






G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience and Vehicles with anti-theft devices. Please contact American Collectors Insurance for additional details.


NOTICE OF INSURANCE INFORMATION PRACTICES CONSUMER REPORTS A consumer report about you or other individuals listed as policyholders, drivers or household members (e.g. driving record, claims history) may be requested in connection with this application, policy amendments and/or renewals. This consumer report information which we have or may obtain will be treated confidentially and will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law. OTHER NON-PUBLIC PERSONAL INFORMATION Information contained in this application and any additional non-public personal information subsequently collected, will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law. YOUR RIGHTS You have the right to see personal information collected about you, and you have the right to correct any information which may be wrong. You may obtain a more detailed description of our information practices and your rights regarding information we collect by viewing our privacy policy online at www.AmericanCollectors.com, calling American Collectors Insurance, or, if you have been issued a policy, you may write us at the address provided with your policy.

FRAUD WARNING

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties,.


Limitations of Use-Insured motorcycle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type transportation. Collector motorcycles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These motorcycles may not be used for any timed or racing events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder or declarations page). Motorcycle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been approved by American Collectors Insurance (subject to state availability). Acknowledgements 1. The information provided to complete the application was provided by me and, to the best of my knowledge, is accurate and true. 2. I have reviewed the attached offer of insurance and accept the coverage limits offered by American Collectors Insurance, Inc. 3. The collector motorcycle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will

remain as such. Furthermore, I will advise American Collectors Insurance of any changes in the named insured. 4. I acknowledge that the collector motorcycle(s) does not currently have any unrepaired damage and further understand that New Hampshire


may operate any motorcycle insured by New Hampshire Insurance Company. 6. Our policies are subject to a non-refundable, minimum earned premium of $50.00. 7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector motorcycle within 20 days.

Any photograph will become property of American Collectors Insurance and will not be returned. APPLICANT’S STATEMENT I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE













Yes No


NAME DATE OF

BIRTH RELATIONSHIP TO APPLICANT

DRIVERS LICENSE NUMBER & STATE YEARS

LICENSED

OPERATES COLLECTOR

VEHICLE EXCLUDE DRIVER?

Applicant

Yes No Yes No

Household Member 2

Yes No Yes No

Household Member 3

Yes No Yes No

Household Member 4

Yes No Yes No

REGULAR USE VEHICLES (YEAR / MAKE / MODEL)

IS THIS A COMPANY VEHICLE?




#1

Yes No

#2

Yes No

#3

Yes No

#4

Yes No

C. DRIVING RECORD


Applicant Yes No

Household Member 2

Yes No

Household Member 3

Yes No

Household Member 4

Yes No

PRODUCER # ____________________ QUOTE #________________________







Veh. 1

Veh. 2

Veh. 3

STORAGE TYPE* STORAGE LOCATION: If different than mailing or garaging address above. Please include County.

Is the Collector Vehicle currently In your possession?

LIST LIENHOLDER / FINANCED OR LEASED

Veh. 1

Yes No

Veh. 2

Yes No

Veh. 3

Yes No



IS VEHICLE MODIFIED OR CUSTOMIZED?







Hobby Related

Activities (I.e. Car shows & car

club events)

Visiting Friends or

Family

Exercising the motor

Occasional General Transportation

(I.e. Running errands & trips to work)

Timed or Racing Events


OTHER* ANNUAL MILEAGE

Veh. 1

Veh. 2

Veh. 3


F. COVERAGES

Please note that the liability coverage purchased from us cannot exceed the limits of your regular use vehicles. PLEASE SELECT THE LIMIT OF COVERAGE DESIRED BELOW. All policies must include Other Than Collision Coverage.


[ $20,000/40,000/5,000] [ $50,000/100,000/25,000] [ $100,000/300,000/50,000]



[ $8,000]



Please refer to the Massachusetts Uninsured/Underinsured Motorist Basic and Increased Limits Selection Form (A1028APC) for available coverage limits. Please complete, sign and attach the form to this application.




TOWING & LABOR FOR COLLECTORS (TLC) PLAN - TLC is a reimbursement based emergency Roadside assistance plan specific for Collector Cars. If you would like to learn more about this affordable plan call us at (800) 360-2277.



INCREASED SPARE PARTS COVERAGE Coverage for additional spare parts that belong on the collector vehicle.






G. DISCOUNTS

Discounts may be available for principal operators who are age 65 or older with at least 10 years of driving experience. Vehicles with anti-theft devices or passive restraint devices. Please contact American Collectors Insurance for additional details.


NOTICE OF INSURANCE INFORMATION PRACTICES CONSUMER REPORTS A consumer report about you or other individuals listed as policyholders, drivers or household members (e.g. driving record, claims history) may be requested in connection with this application, policy amendments and/or renewals. This consumer report information which we have or may obtain will be treated confidentially and will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law. OTHER NON-PUBLIC PERSONAL INFORMATION Information contained in this application and any additional non-public personal information subsequently collected, will not be disclosed to non-affiliated third parties without your prior authorization unless permitted or required by law. YOUR RIGHTS You have the right to see personal information collected about you, and you have the right to correct any information which may be wrong. You may obtain a more detailed description of our information practices and your rights regarding information we collect by viewing our privacy policy online at www.AmericanCollectors.com, calling American Collectors Insurance, or, if you have been issued a policy, you may write us at the address provided with your policy.

FRAUD WARNING

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties,.


Limitations of Use-Insured vehicle(s) may be used for hobby activities and pleasure drives. Pleasure drives do not include general or daily type transportation. Only under the Freedom Tier option with a mileage limitation of 7,500 is occasional general use acceptable (subject to state availability). Collector vehicles insured with New Hampshire Insurance Company cannot be used as a substitute for your daily use vehicle. These vehicles may not be used for any timed, racing or Driver’s Education events. Annual mileage may not exceed the mileage tier you purchased (refer to your policy binder or declarations page). Vehicle(s) must be kept in a completely enclosed, locked garage when not in use; unless an alternate garaging situation has been approved by American Collectors Insurance (subject to state availability). Acknowledgements 1. The information provided to complete the application was provided by me and, to the best of my knowledge, is accurate and true. 2. I have reviewed the attached offer of insurance and accept the coverage limits offered by American Collectors Insurance, Inc. 3. The collector vehicle(s) insured by New Hampshire Insurance Company is or will be titled in my name only (or myself and my spouse) and will

remain as such. Furthermore, I will advise American Collectors Insurance of any changes in the named insured. 4. I acknowledge that the collector vehicle(s) does not currently have any unrepaired damage and further understand that New Hampshire Insurance

Company is not responsible for any damage that was sustained to the insured vehicle(s) prior to the issuance of this policy. 5. I understand that no one in or out of my house with less than ten (10) years’ driving experience (unless specifically listed as a driver on this policy)

may operate any vehicle insured by New Hampshire Insurance Company. 6. Our policies are subject to a non-refundable, minimum earned premium of $50.00. 7. In order to continue coverage, the insured must read and sign this legal agreement and provide a photo of each collector vehicle within 20 days.

Any photograph will become property of American Collectors and will not be returned. APPLICANT’S STATEMENT I acknowledge that I have read and understood this application in its entirety and agree with all terms and conditions set forth under this application. I agree that this application and any materials submitted by me or on my behalf, shall be incorporated into and shall constitute a part of any policy issued, whether physically attached to the policy or not. Failure to comply with any of the above terms and conditions may result in coverage being denied. PROPOSED EFFECTIVE DATE


x DATE




AMENDATORY ENDORSEMENT FOR ANTIQUE MOTORCYCLE COVERAGE MASSACHUSETTS

With respect to “motorcycles” and coverages described in the Declarations, the provisions of the Policy apply unless modified by this endorsement. I. DEFINITIONS Item J. is deleted and replaced by the following: J. “Your covered auto” means: 1. Any “motorcycle” as shown in the Declarations. 2. Any newly acquired “motorcycle” of which you

acquire ownership during the policy period, provided that you ask us to insure it within thirty (30) days after you become the owner. If the vehicle replaces one shown in the Declarations, you have to ask us to insure it within thirty (30) days only if you wish Coverage for Damage to Your Auto to apply to the replacement vehicle. If you ask us to insure a newly acquired “motorcycle” after the thirty (30) days has elapsed, any coverage we provide for a newly acquired “motorcycle” will begin at the time we receive your request for coverage.


“Motorcycle” means a motorcycle that is: 1. Considered to be appreciating in value, and is

either: a. Of unique or rare design; or b. Of limited production. 2. Used for: exhibitions; club activities; parades;

or other functions of public interest; occasional pleasure drives;



II. PART A - LIABILITY COVERAGE Item B. under INSURING AGREEMENT is deleted

and replaced with the following: B. “Insured” as used in this Part means: 1. You or any “family member” for the

ownership, maintenance, or use of “your covered auto.”

2. Any person using “your covered auto.” 3. For “your covered auto,” any person or

organization but only with respect to legal responsibility for acts or omissions of a person for whom coverage is afforded under this Part.

EXCLUSIONS A, item 10 is added with respect to any vehicle for which the Declarations indicates that the passenger hazard is excluded:

10. We do not provide Liability Coverage for any

“Insured” for “bodily injury” to any person or “insured” while “occupying” the described “motorcycle”.


following: 1. We do not provide Liability Coverage for the

ownership, maintenance, or use of any vehicle which is designed mainly for use off public roads.

This exclusion (B.1.) does not apply while such

vehicle is being used by an “insured” in a medical emergency.


EXCLUSIONS, item 1. is deleted and replaced by the

following: 1. We do not provide Medical Payments Coverage

for any person or “insured” for “bodily injury” sustained while “occupying” “your covered auto” unless it is insured for Medical Payments Coverage under this endorsement.

IV. PART D - COVERAGE FOR DAMAGE TO YOUR

AUTO

Under LIMIT OF LIABILITY Sections A. and B. are deleted and replaced by the following:

AGREED VALUE COVERAGE In the event of loss to “your covered auto” we will, subject





B. Pay the agreed value shown on the Declarations page

less any deductible applicable, if the amount to repair or replace the property is equal to or greater than the limit of liability or if the vehicle is deemed to be a total loss. The agreed value for each vehicle shown in the Declarations is increased by two percent (2%) after each quarter to a maximum of six percent (6%) after the effective date.

Upon expiration of the policy period, the limit reverts back to the agreed value shown in the Declarations. This amount is used to process your renewal unless you request a change in the amount of insurance to which we must also agree.

We extend our limit of liability to cover any

additional or replacement “motorcycle” acquired by you during the policy period but not to exceed:

1. The verifiable value; or 2. The highest agreed value for any single

“motorcycle” currently on the policy; or 3. $25,000; or 4. The purchase price, whichever is less. Such additional or replacement vehicles must be










Medical Payments,




Agreed Value Other than Collision and Collision. WARNING - When a named excluded person operates a vehicle, all liability coverage is void - no one is insured. Owners of the vehicle and others legally responsible for the acts of the named excluded person remain fully personally responsible. Name of Excluded Person(s):








following:



B. We do not provide Liability Coverage for the ownership, maintenance or use of:

1. Any vehicle which: a. Is designed mainly for use off public















entirety. TRANSPORTATION EXPENSES is deleted in its

entirety. The following coverage is added:

SPARE PARTS COVERAGE


We do not cover:


and control.



















EXCLUSIONS, 11 and 13 are deleted in its entirety. The following EXCLUSIONS are added:

14. Loss to any covered auto being maintained,

used, or held by any person or dealer for consignment or sale.




LIMIT OF LIABILITY Sections A. and B. are deleted and replaced by the

following: AGREED VALUE COVERAGE In the event of loss to “your covered auto” we will, subject









PAYMENT OF LOSS, Paragraph 3, is deleted and replaced with the following:

If we pay for loss in money, our payment will include the applicable sales tax for the damaged or stolen property subject to the maximum limit of liability shown in the Declarations.


replaced with the following: OTHER SOURCES OF RECOVERY

If other sources of recovery also cover the loss, we will pay



VEHICLE TRAILER




IV. PART E - DUTIES AFTER AN ACCIDENT OR

LOSS Section D is deleted and replaced with the following: D. A person seeking Coverage For Damage To Your Auto

must also: 1. Take reasonable steps after loss to protect "your

covered auto" and their equipment from further loss. We will pay reasonable expenses incurred to do this.

2. Promptly notify the police if "your covered auto" including its parts or accessories, is stolen.

3. Permit us to inspect and appraise the damaged property before its repair or disposal.





MASSACHUSETTS










[ $20,000/$40,000] [ $50,000/$100,000] [ $100,000/$100,000] [ $100,000/$300,000] [ $300,000/$300,000] [ $250,000/$500,000] [ $300,000/$500,000] [ $500,000/$500,000]

Reject Underinsured Motorist coverage entirely I have read and understand the contents of this notice regarding Uninsured/Underinsured Motorists Coverage. I understand and agree that this coverage election applies to my Antique [Automobile] Policy and future renewals until I advise the Company or its authorized representative, in writing, to the contrary.


X DATE

/ /






Policy Declaration Page Producer


Named Insured

This Declaration Page with policy provisions completes this policy.

Collector Vehicles


Selected Coverages



Vehicle Premium


Alternate Addresses

Excluded Drivers










Secretary President


Page 1 of 1

78052 (04/14)

AIG Property Casualty U.S. Privacy and Data Security Notice

About This Notice This Privacy and Data Security Notice applies only to your Personal Information (see definition below) obtained by one of the property-casualty insurance company subsidiaries or affiliates of American International Group, Inc. listed at the end of this notice (collectively, the “AIG Companies” or “we”) in connection with the products or services one of those companies provided primarily for your personal, family, or household purposes in connection with which you are receiving this notice. The AIG Companies have established practices, procedures and system protections that are designed to help protect the privacy and security of Personal Information that we collect in the course of conducting our business. This notice outlines how we collect, handle, and disclose Personal Information about you. The term “Personal Information,” as used in this Privacy and Data Security Notice, means information that identifies you personally. Examples of Personal Information include, but are not limited to, a first and last name, a home or other physical address, an email address, a financial account or credit card number, a driver’s license number, and information on your physical condition or health status. I. Information Privacy We may collect Personal Information from applications, enrollment forms, in claims processing, or in your other interactions with us and with our Affiliates. We may also collect Personal Information from credit reporting agencies and other third parties in connection with the sale of our products to you. We will collect Personal Information only in accordance with applicable laws or regulations, whether we collect it in response to your request for a product or service from us or otherwise. Information Sharing We may share your Personal Information with Affiliates and Non-Affiliates as described below. With our Affiliates: Our Affiliates may include other insurance companies, insurance holding companies, insurance agents and agencies, claims administrators, marketing companies, e-commerce service providers, and companies providing administrative services. We may share your Personal Information, including Personal Information of a health nature, with our Affiliates that assist us in servicing your insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share your Personal Information with our Affiliates for the purpose of detecting and preventing fraud, as directed or authorized by you, or as otherwise permitted or required by law. With Non-Affiliates: We may share your Personal Information, including Personal Information of a health nature, with Non-Affiliates that assist us in servicing your insurance policies. Examples are administration (billing and collections), risk management, underwriting, and claims handling. We may also share your Personal Information with Non-Affiliates for the purpose of detecting and preventing fraud, as directed or authorized by you, or as otherwise permitted or required by law. We may also enter into joint marketing agreements with Non-Affiliates to share your non-health Personal Information as permitted by law. These Non-Affiliates may include providers of financial products or services such as insurance companies, financial institutions, and securities firms. Because we do not share Personal Information with either Affiliates or Non-Affiliates in any other way, there is no need for an opt-out process in our privacy procedures.

78052 (04/14)

For California and Vermont Residents: If it becomes necessary to share your Personal Information with Non-Affiliates other than as specifically allowed by law, we will not do so without first obtaining your permission. II. Data Security To help prevent unwarranted disclosure of your Personal Information and secure it from theft, we utilize secure computer networks. Access is restricted to those persons who have a business need to use your Personal Information to provide products or services to you. We also maintain physical, electronic, and procedural safeguards designed to protect your Personal Information in compliance with federal and state privacy and information security laws. Non-Affiliates that assist us in servicing insurance policies or who enter into joint marketing agreements with us are required to take measures to maintain the security of your Personal Information in compliance with federal and state privacy and information security laws. III. Maintaining Personal Information We also maintain procedures to ensure that the Personal Information we collect is accurate, up-to-date, and as complete as possible. If you believe the information we have about you in our records or files is incomplete or inaccurate, you may request that we make additions or corrections, or if it is feasible, that we delete this information from our files. You may make this request in writing to (include your name, address and policy number):

Chief Privacy Officer AIG Property Casualty

175 Water Street 15th Floor New York, NY 10038 Fax: 212 458-7081

E-Mail: [email protected] Special Notice: You can obtain access to any non-public Personal Information we have about you if you properly identify yourself and submit a written request to the address above describing the information you want to review. We will also tell you the identity, if recorded, of persons to whom we have disclosed your non-public Personal Information within the preceding two years. You may request that we correct, amend or delete information about you. If we do so, we will notify organizations that provided us with that information and, at your request, persons who received that information from us within the preceding two years. If we cannot grant your request to correct, amend or delete the information, you may give us a written statement of the reasons you disagree, which we will place in your file and give to the same parties who would have been notified of the requested change.

Our Customers Can Depend on Us We are committed to maintaining our trusted relationship with our Customers. We consider it our privilege to serve our Customers’ insurance and financial needs and we value the trust they have placed in us. Our Customers’ privacy is a top priority. We will continue to monitor our practices in order to protect that privacy and will comply with state privacy laws that require more restrictive practices than those set out in this notice. Important Information Concerning the Applicability and Future Changes to this Privacy and Data Security Notice

We may change this Privacy and Data Security Notice from time to time, and if particular changes are required by law to be communicated to you, we will do so. The AIG Companies include: American Home Assurance Company; AIG Assurance Company; AIG Property Casualty Company; AIG Specialty Insurance Company; Commerce and Industry Insurance Company; Granite State Insurance Company; Illinois National Insurance Co.; Lexington Insurance Company; National Union Fire Insurance Company of Pittsburgh, Pa.; National Union Fire Insurance Company of Vermont; New Hampshire Insurance Company; The Insurance Company of the State of Pennsylvania; American International Life Assurance Company of New York; and American General Life Insurance Company of Delaware.

Effective Date 7/1/2017 New Hampshire Insurance Company

Statement of Variability

Form Number Form Name Variability

AB3810EPC-

0316

Named Driver Exclusion Endorsement Massachusetts Named of Excluded

Person(s), signature,

date

ANA0001D-0316 Policy Declaration Page Insured & vehicle

information;

Coverages, signatures

AJ9898JPC-0316 Antique & Collectible Vehicle Policy Officer Signatures

A1028APC-0316 UNINSURED/UNDERINSURED MOTORISTS

SELECTION/REJECTION FORM

MASSACHUSETTS

Name, date, signature,

selection of limits

AH9675ERR-

0316


MASSACHUSETTS

Year, body type,

model, policy number,

limits

Filer’s Signature 6/13/2016

Howard Chandler

Senior State Filing Analyst

Martin & Company

1

· $50 for locksmith assistance if you are locked out of your insured vehicle, providing the...

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