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2770.1900 SURCHARGE PLAN FORMATS.

The formats contained in this part must be used, but additional information may be included.

A.

One vehicle insured.

Coverage Premium with
no accidents
Premium including surcharge for one chargeable accident Premium including surcharge for two chargeable accidents
Bodily injury, property damage $ 80 . $ _ $ _
Uninsured motorist $ 5 . $ _ $ _
Personal injury protection $ 40 . $ _ $ _
Comprehensive $ 25 . $ _ $ _
Collision $ 50 . $ _ $ _
Total Premium $200 $ $

B.

Two vehicles insured. Accidents chargeable to the principal operator of vehicle number one, while operating vehicle number one.

(1)

Vehicle number one.

Coverage Premium with
no accidents
Premium including surcharge for one chargeable accident Premium including surcharge for two chargeable accidents
Bodily injury, property damage $ 80 . $ _ $ _
Uninsured motorist $ 5 . $ _ $ _
Personal injury protection $ 40 . $ _ $ _
Comprehensive $ 25 . $ _ $ _
Collision $ 50 . $ _ $ _
Total Premium $200 $ $

(2)

Vehicle number two.

Coverage Premium with
no accidents
Premium including surcharge for one chargeable accident Premium including surcharge for two chargeable accidents
Bodily injury, property damage $120 . $ _ $ _
Uninsured motorist $ 5 . $ _ $ _
Personal injury protection $ 60 . $ _ $ _
Comprehensive $ 40 . $ _ $ _
Collision $ 75 . $ _ $ _
Total Premium $300 $ $

Statutory Authority:

MS s 65B.133

Published Electronically:

September 14, 2007

Official Publication of the State of Minnesota
Revisor of Statutes